Provider Demographics
NPI:1699549352
Name:GOTHAM EARLS, HEATHER E
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:GOTHAM EARLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELOISE
Other - Last Name:GOTHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16030 EAST HIGH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-1238
Practice Address - Country:US
Practice Address - Phone:440-632-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13399225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist