Provider Demographics
NPI:1861711764
Name:LOWE, HEATHER (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LOWE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1513
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-9102
Mailing Address - Country:US
Mailing Address - Phone:208-800-2233
Mailing Address - Fax:844-990-4180
Practice Address - Street 1:280 S ACADEMY AVE STE 120
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6562
Practice Address - Country:US
Practice Address - Phone:208-800-2233
Practice Address - Fax:844-990-4180
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID820510764174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805633700Medicaid
ID805633700Medicaid