Provider Demographics
NPI:1699485714
Name:SPANG, HEIDEROSE A (LMT)
Entity type:Individual
Prefix:
First Name:HEIDEROSE
Middle Name:A
Last Name:SPANG
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 1:4601 E ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9303
Mailing Address - Country:US
Mailing Address - Phone:480-773-9997
Mailing Address - Fax:
Practice Address - Street 1:4601 E ANGELA DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9303
Practice Address - Country:US
Practice Address - Phone:480-773-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-10555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty