Provider Demographics
NPI:1770606105
Name:PETERSON, HEIDI JILL (ATC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JILL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E. THIRD AVE.
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1334
Mailing Address - Country:US
Mailing Address - Phone:509-838-2531
Mailing Address - Fax:509-624-0403
Practice Address - Street 1:505 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1426
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-624-0403
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1600538082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer