Healthcare Provider Details

I. General information

NPI: 1235823923
Provider Name (Legal Business Name): HEATHER ATKINS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SHADWELL AVE
FLORA IL
62839-2310
US

IV. Provider business mailing address

407 BRIAN DR
OLNEY IL
62450-2401
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-8361
  • Fax:
Mailing address:
  • Phone: 618-320-1572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number16000927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: