Provider Demographics
NPI:1316146657
Name:SAM, HEIDI JOY (MASSAGE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JOY
Last Name:SAM
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-0022
Mailing Address - Country:US
Mailing Address - Phone:509-322-4536
Mailing Address - Fax:
Practice Address - Street 1:130 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-322-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist