Healthcare Provider Details

I. General information

NPI: 1962416826
Provider Name (Legal Business Name): DINA HEIJSELAAR-KILIAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DINA HAARLEM PT

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5587 BROADWAY
MERRILLVILLE IN
46410-2695
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 219-887-9021
  • Fax: 219-887-9022
Mailing address:
  • Phone: 630-296-2223
  • Fax: 630-759-3251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05005302A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: