Provider Demographics
NPI:1316259666
Name:HEITZMAN, KERI ANN (LMT, CPT, NCBTMB)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:ANN
Last Name:HEITZMAN
Suffix:
Gender:F
Credentials:LMT, CPT, NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 SW VALERIA VIEW DR
Mailing Address - Street 2:209
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-7074
Mailing Address - Country:US
Mailing Address - Phone:541-844-9495
Mailing Address - Fax:
Practice Address - Street 1:10215 SW PARK WAY
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5036
Practice Address - Country:US
Practice Address - Phone:541-844-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8190225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist