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General NPI Number Information
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NPI Number | 1144384652
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Entity Type | Organization
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Legal Business Name | BLUE HERON PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3708 E RIPPLE RD
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City | CAMP VERDE
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State | AZ
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Zip | 86322-8102
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Country | US
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Telephone | 212-947-7039
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Fax |
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Provider Business Mailing Address
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Address Line | 3708 E RIPPLE RD
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City | CAMP VERDE
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State | AZ
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Zip | 86322-8102
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Country | US
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Telephone | 212-947-7039
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARY KATHLEEN SAWERT
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Credential |
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Telephone | 212-947-7039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1495
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License Number State | AZ
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