Provider Demographics
NPI:1013047570
Name:THORNSBERRY, HEATHER ANN (PT/DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:THORNSBERRY
Suffix:
Gender:F
Credentials:PT/DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT/DPT
Mailing Address - Street 1:218 OUTRE STREET
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651
Mailing Address - Country:US
Mailing Address - Phone:276-832-1154
Mailing Address - Fax:
Practice Address - Street 1:383 CORBIN CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-526-2919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87029591Medicaid
KY87029591Medicaid