Basic Information
Provider Information | |||||||||
NPI: | 1700939253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REPAC | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WATTS | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1233 N 30TH ST | ||||||||
Address2: |   | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591010127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062386400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 50 27TH ST W | ||||||||
Address2: | SUITE B | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591028601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4066519099 | ||||||||
FaxNumber: | 4066514332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2007 | ||||||||
LastUpdateDate: | 01/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 960PT | MT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 60658 | 01 | MT | BCBS | OTHER | 346834 | 05 | MT |   | MEDICAID |