Healthcare Provider Details

I. General information

NPI: 1023461407
Provider Name (Legal Business Name): HEATHER FARRELL M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3821 ATLANTIC AVE SUITE F
LONG BEACH CA
90807-3534
US

IV. Provider business mailing address

3821 ATLANTIC AVE SUITE F
LONG BEACH CA
90807-3534
US

V. Phone/Fax

Practice location:
  • Phone: 562-940-5450
  • Fax: 562-424-3235
Mailing address:
  • Phone: 562-940-5450
  • Fax: 562-424-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number68134
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number68134
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: