Basic Information
| Provider Information | |||||||||
| NPI: | 1386730034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOONAN | ||||||||
| FirstName: | HEIDI | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 MUDGETT FARM RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054649309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026445565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4968 MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | STOWE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056724885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022535694 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 040-0002657 | VT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1008799 | 05 | VT | MEDICAID |