=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639969447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI MALBURG PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 GLENDALE MILFORD RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45215-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-733-3370
-----------------------------------------------------
Fax | 513-733-3370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1017 ASCOT DR
-----------------------------------------------------
City | MAINEVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45039-8911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-600-6568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------