Provider Demographics
NPI:1649433269
Name:LOPEZ, HEATHER PAULINE (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:PAULINE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-960-0935
Practice Address - Street 1:1673 W SHORELINE DR STE 230
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6752
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL-10035225100000X
IDPT-3958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty