Provider Demographics
NPI:1124121454
Name:CHERNYSHOV, HEATHER MARIE (MS, ATC, NCTMB)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:CHERNYSHOV
Suffix:
Gender:F
Credentials:MS, ATC, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-2088
Mailing Address - Country:US
Mailing Address - Phone:802-860-1358
Mailing Address - Fax:
Practice Address - Street 1:115 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2088
Practice Address - Country:US
Practice Address - Phone:802-860-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104-00000872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer