Healthcare Provider Details

I. General information

NPI: 1902166853
Provider Name (Legal Business Name): HEATHER B ELLIOTT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 SW 30TH ST STE 100
CORVALLIS OR
97331-8629
US

IV. Provider business mailing address

3917 BEAR HOLLOW RD
JOELTON TN
37080-8912
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT10193631
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: