Provider Demographics
NPI:1740721232
Name:DETWILER, HEATHER (PTA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DETWILER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SWAINSON CT
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7808
Mailing Address - Country:US
Mailing Address - Phone:803-361-8829
Mailing Address - Fax:
Practice Address - Street 1:2705 LEAPHART RD.
Practice Address - Street 2:CAROLINA GARDENS
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-939-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3288225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant