Healthcare Provider Details

I. General information

NPI: 1225877640
Provider Name (Legal Business Name): HEATHER MATHEW M.C.L.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER LAND M.C.L.C.

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W IRIS DRIVE
NASHVILLE TN
37204
US

IV. Provider business mailing address

636 FOSTER LN
MOUNT JULIET TN
37122
US

V. Phone/Fax

Practice location:
  • Phone: 615-678-7993
  • Fax:
Mailing address:
  • Phone: 719-510-3941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number75781113
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: