Healthcare Provider Details

I. General information

NPI: 1891192548
Provider Name (Legal Business Name): HEATHER SUE TALLEY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W 300 N
VALPARAISO IN
46385-9203
US

IV. Provider business mailing address

624 W 300 N
VALPARAISO IN
46385-9203
US

V. Phone/Fax

Practice location:
  • Phone: 219-707-6664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002150A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: