=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639242514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANET DELORES HEASLEY D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 10/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 MILL ST
-----------------------------------------------------
City | ORTONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48462-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-627-7682
-----------------------------------------------------
Fax | 248-627-7685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 957 EVERGREEN RDG
-----------------------------------------------------
City | ORTONVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48462-9746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-627-5066
-----------------------------------------------------
Fax | 248-627-7685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 5101013119
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------