Provider Demographics
NPI:1770955262
Name:COOK, HEATHER ALISON (LMT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ALISON
Last Name:COOK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14385 SE LUSTED RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-7551
Mailing Address - Country:US
Mailing Address - Phone:575-312-9391
Mailing Address - Fax:
Practice Address - Street 1:223 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7605
Practice Address - Country:US
Practice Address - Phone:503-667-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20464174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist