Provider Demographics
NPI:1548248693
Name:SOSSOMAN, HEATHER WILES (MPT)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:WILES
Last Name:SOSSOMAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-6713
Mailing Address - Country:US
Mailing Address - Phone:954-683-0611
Mailing Address - Fax:
Practice Address - Street 1:3240 MAPLE LN
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-6713
Practice Address - Country:US
Practice Address - Phone:954-683-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-07
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26798225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004154700Medicaid
NC7211644Medicaid
NC079KVOtherBCBS