Provider Demographics
NPI:1669208476
Name:LAVANWAY, HEIDI
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:LAVANWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 BROOKVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:VT
Mailing Address - Zip Code:05680-4603
Mailing Address - Country:US
Mailing Address - Phone:802-279-6995
Mailing Address - Fax:
Practice Address - Street 1:200 ELM ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2205
Practice Address - Country:US
Practice Address - Phone:802-223-0954
Practice Address - Fax:802-225-6728
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT164.0001707225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist