Provider Demographics
NPI:1215077854
Name:HERON, CAROL MARIE (LPTA, CLT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:MARIE
Last Name:HERON
Suffix:
Gender:F
Credentials:LPTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 RAINSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1944
Mailing Address - Country:US
Mailing Address - Phone:931-920-0089
Mailing Address - Fax:931-906-4173
Practice Address - Street 1:1808 HAYNES ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4547
Practice Address - Country:US
Practice Address - Phone:931-906-4170
Practice Address - Fax:931-906-4173
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3253225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant