MEDICARE: MRS. CAROL MARIE HERON LPTA, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	3253	TN

General Provider Information

NPI Number	:	1215077854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL MARIE HERON LPTA, CLT

Provider Business Mailing Address
First Line	:	701 RAINSWOOD CT
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-1944
Country	:	US
Telephone Number	:	931-920-0089
Fax Number	:	931-906-4173

Provider Business Practice Location Address
First Line	:	1808 HAYNES ST
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-4547
Country	:	US
Telephone Number	:	931-906-4170
Fax Number	:	931-906-4173

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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