Provider Demographics
NPI:1154419653
Name:WACKSMAN, HEATHER LYNN (MPT)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:LYNN
Last Name:WACKSMAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:HARMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1 HARMON DR
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-5451
Mailing Address - Country:US
Mailing Address - Phone:207-240-1571
Mailing Address - Fax:
Practice Address - Street 1:50 FOREST FALLS DR
Practice Address - Street 2:SUITE 2
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6937
Practice Address - Country:US
Practice Address - Phone:207-846-8725
Practice Address - Fax:207-846-8728
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2756063001OtherCIGNA
ME626281OtherHARVARD PILGRIM
ME098997OtherANTHEM BCBS
11507672OtherCAQH
ME432475009Medicaid
11507672OtherCAQH