Healthcare Provider Details

I. General information

NPI: 1942442389
Provider Name (Legal Business Name): HEATHER WONDERLICH P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 HILLCREST DR
BELLEVUE NE
68005-3663
US

IV. Provider business mailing address

13616 CALIFORNIA ST STE 100
OMAHA NE
68154-5336
US

V. Phone/Fax

Practice location:
  • Phone: 402-650-8954
  • Fax:
Mailing address:
  • Phone: 402-496-0404
  • Fax: 402-496-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2729
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: