Provider Demographics
NPI:1811526940
Name:RIDENOURE, HEATHER (PT, ATC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RIDENOURE
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 S GROVE DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8817
Mailing Address - Country:US
Mailing Address - Phone:479-530-8699
Mailing Address - Fax:
Practice Address - Street 1:5103 S GROVE DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8817
Practice Address - Country:US
Practice Address - Phone:479-530-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist