Healthcare Provider Details

I. General information

NPI: 1952414906
Provider Name (Legal Business Name): TINA LOUISE HEYDENBURG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA LOUISE HEYDENBURG PT

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1897 ISLAND WALK WAY UNIT 5
FERNANDINA BEACH FL
32034-1948
US

IV. Provider business mailing address

PO BOX 949
ROME GA
30162-0949
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-4664
  • Fax: 904-261-5852
Mailing address:
  • Phone: 706-236-2774
  • Fax: 706-236-2783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 16749
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9844
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: