1609822014 NPI number — HEATHER NICOLE HABERHERN OT

Table of content: HEATHER NICOLE HABERHERN OT (NPI 1609822014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609822014 NPI number — HEATHER NICOLE HABERHERN OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABERHERN
Provider First Name:
HEATHER
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
HEATHER
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609822014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8823 PRODUCTION LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OOLTEWAH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37363-6511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5022 OLD GODSEY LN
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343-6600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-870-3573
Provider Business Practice Location Address Fax Number:
423-870-3574
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3156797 . This is a "BCBST - GROUP NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0446652 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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