Healthcare Provider Details

I. General information

NPI: 1902060205
Provider Name (Legal Business Name): AUSTIN JAMES HEFFNER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 W SUDBURY DR STE C
BLOOMINGTON IN
47403-3812
US

IV. Provider business mailing address

2201 W SUDBURY DR STE C
BLOOMINGTON IN
47403-3812
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-1933
  • Fax: 812-333-3991
Mailing address:
  • Phone: 812-333-1933
  • Fax: 812-333-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05009367A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: