Provider Demographics
NPI:1841658465
Name:PARK, HEATHER NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:NICOLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6551 FIVE POINTS RD.
Mailing Address - Street 2:
Mailing Address - City:CREEKSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:15732
Mailing Address - Country:US
Mailing Address - Phone:724-599-8960
Mailing Address - Fax:
Practice Address - Street 1:429 MANOR DRIVE
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931
Practice Address - Country:US
Practice Address - Phone:814-472-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist