Provider Demographics
NPI:1346782125
Name:BROGDON, HEIDI (LMT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:BROGDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12860 NW JARVIS PL APT 4
Mailing Address - Street 2:
Mailing Address - City:BANKS
Mailing Address - State:OR
Mailing Address - Zip Code:97106-6059
Mailing Address - Country:US
Mailing Address - Phone:971-226-8166
Mailing Address - Fax:
Practice Address - Street 1:12860 NW JARVIS PL APT 4
Practice Address - Street 2:
Practice Address - City:BANKS
Practice Address - State:OR
Practice Address - Zip Code:97106-6059
Practice Address - Country:US
Practice Address - Phone:971-226-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21891225700000X
AZMT-20575225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist