Provider Demographics
NPI:1225877640
Name:MATHEW, HEATHER (MCLC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MCLC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:LAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MCLC
Mailing Address - Street 1:636 FOSTER LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122
Mailing Address - Country:US
Mailing Address - Phone:719-510-3941
Mailing Address - Fax:
Practice Address - Street 1:603 W IRIS DRIVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204
Practice Address - Country:US
Practice Address - Phone:615-678-7993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN75781113171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach