Provider Demographics
NPI:1356215834
Name:MAGOMBO, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MAGOMBO
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 RETFORD DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-3339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16414 SOUTHPARK DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8396
Practice Address - Country:US
Practice Address - Phone:317-815-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician