Healthcare Provider Details

I. General information

NPI: 1245194059
Provider Name (Legal Business Name): TARA HEISEY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200
PONDERAY ID
83852-5005
US

IV. Provider business mailing address

504 N FOREST AVE
SANDPOINT ID
83864-1925
US

V. Phone/Fax

Practice location:
  • Phone: 208-205-9559
  • Fax:
Mailing address:
  • Phone: 717-368-2462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMSG010351
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: