Basic Information
| Provider Information | |||||||||
| NPI: | 1639530702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAW | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT, ATC, LAT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FARISS | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT, ATC, LAT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3090 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027452939 | ||||||||
| FaxNumber: | 6027452962 | ||||||||
| Practice Location | |||||||||
| Address1: | 3090 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027452939 | ||||||||
| FaxNumber: | 6027452963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1271261 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | LPT-012927 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 311736 | 05 | AZ | MEDICAID |