Provider Demographics
NPI:1104969773
Name:RICHERSON, HEATHER DIANE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DIANE
Last Name:RICHERSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 MELBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3952
Mailing Address - Country:US
Mailing Address - Phone:801-487-4506
Mailing Address - Fax:
Practice Address - Street 1:1952 FORT UNION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6877
Practice Address - Country:US
Practice Address - Phone:801-942-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3131802401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist