Healthcare Provider Details

I. General information

NPI: 1962868950
Provider Name (Legal Business Name): SHAUN HEINZEROTH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 11/02/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10547 MONTOMGERY ROAD
CINCINNATI OH
45242
US

IV. Provider business mailing address

10547 MONTOMGERY ROAD
CINCINNATI OH
45242
US

V. Phone/Fax

Practice location:
  • Phone: 513-346-1534
  • Fax:
Mailing address:
  • Phone: 513-346-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018948
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.10259
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: