Provider Demographics
NPI:1740678440
Name:ROBERSON, HEIDI (LMP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:ROBERSON
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 1:12433 ADMIRALTY WAY
Mailing Address - Street 2:APT O207
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8034
Mailing Address - Country:US
Mailing Address - Phone:602-680-0096
Mailing Address - Fax:
Practice Address - Street 1:111 SUNSET AVE N
Practice Address - Street 2:SUITE 101
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3229
Practice Address - Country:US
Practice Address - Phone:425-582-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60493339225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist