Healthcare Provider Details

I. General information

NPI: 1912113903
Provider Name (Legal Business Name): REBECCA HEFFERNAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N VINE ST
URBANA IL
61802-2700
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-3330
  • Fax: 217-344-4465
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070007033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: