Provider Demographics
NPI:1588066039
Name:HEACOCK, HANNAH (LMT)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:HEACOCK
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 1:10151 SW BARBUR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5931
Mailing Address - Country:US
Mailing Address - Phone:503-245-0454
Mailing Address - Fax:
Practice Address - Street 1:10151 SW BARBUR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5931
Practice Address - Country:US
Practice Address - Phone:503-245-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19485172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist