Provider Demographics
NPI:1740453885
Name:CARSON, HEIDI SUE (LMP)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:SUE
Last Name:CARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:WELLPINIT
Mailing Address - State:WA
Mailing Address - Zip Code:99040-0082
Mailing Address - Country:US
Mailing Address - Phone:509-885-0155
Mailing Address - Fax:
Practice Address - Street 1:235 W BRAODWAY AVE.
Practice Address - Street 2:
Practice Address - City:REARDAN
Practice Address - State:WA
Practice Address - Zip Code:99029
Practice Address - Country:US
Practice Address - Phone:509-885-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist