Provider Demographics
NPI:1811074800
Name:KLOS, HEATHER M (PT)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:M
Last Name:KLOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 NE CUSHING DR STE 150
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1590 NE 3RD ST STE B
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-416-7476
Practice Address - Fax:541-416-7478
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-12-02
Deactivation Date:2015-06-23
Deactivation Code:
Reactivation Date:2015-07-20
Provider Licenses
StateLicense IDTaxonomies
OR63002225100000X
WAPT10151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8866988Medicare PIN