Basic Information
Provider Information | |||||||||
NPI: | 1609100635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEAVEN | ||||||||
FirstName: | CHANDRA | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEAVEN | ||||||||
OtherFirstName: | CHANDRA | ||||||||
OtherMiddleName: | DENISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3608 CHAGFORD LN | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283064619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014370444 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 PAMALEE DR | ||||||||
Address2: | HIGHLAND HOUSE SNF | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283011700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104882295 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2009 | ||||||||
LastUpdateDate: | 08/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11369 | NC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.