Healthcare Provider Details

I. General information

NPI: 1477354058
Provider Name (Legal Business Name): EZEKIEL HEYDENREICH PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 N LITCHFIELD RD STE 310
GOODYEAR AZ
85395-1397
US

IV. Provider business mailing address

9042 S 169TH DR
GOODYEAR AZ
85338-4744
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-0734
  • Fax:
Mailing address:
  • Phone: 978-853-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-034092
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: