Provider Demographics
NPI:1932417565
Name:STARR, HEATHER BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:BROOKE
Last Name:STARR
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 1:1617 PARK PLACE AVE
Mailing Address - Street 2:#110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1300
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:1617 PARK PLACE AVE
Practice Address - Street 2:#110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1300
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2072768225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX207164901Medicaid
TX456606Medicare PIN