Provider Demographics
NPI:1730624669
Name:MELANSON, HEATHER DIANE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DIANE
Last Name:MELANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DIANE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:1600 STONEY RIDGE CT APT 8
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-4622
Mailing Address - Country:US
Mailing Address - Phone:661-433-5758
Mailing Address - Fax:
Practice Address - Street 1:1600 STONEY RIDGE CT APT 8
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4622
Practice Address - Country:US
Practice Address - Phone:661-433-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20000149322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer