Provider Demographics
NPI:1588105431
Name:WILLARD, HEATHER LYNNE (LAT, CSCS)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNNE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 LONG RUN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-6344
Mailing Address - Country:US
Mailing Address - Phone:512-426-1178
Mailing Address - Fax:
Practice Address - Street 1:351 LONG RUN
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-6344
Practice Address - Country:US
Practice Address - Phone:512-426-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-12
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT24222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer