Provider Demographics
NPI:1124773569
Name:THOMAS, HEATHER LEIGH (ATC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 MARJORIE ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-5349
Mailing Address - Country:US
Mailing Address - Phone:228-313-1680
Mailing Address - Fax:
Practice Address - Street 1:2030 14TH ST BLDG 1830
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5302
Practice Address - Country:US
Practice Address - Phone:559-908-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3208232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer