MEDICARE: HEATHER MARIE RICHARDVILLE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05011633A	IN

General Provider Information

NPI Number	:	1699223289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER MARIE RICHARDVILLE DPT

Provider Business Mailing Address
First Line	:	10006 AUBURN PARK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2389
Country	:	US
Telephone Number	:	260-497-7191
Fax Number	:	260-497-7791

Provider Business Practice Location Address
First Line	:	10006 AUBURN PARK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2389
Country	:	US
Telephone Number	:	260-497-7191
Fax Number	:	260-497-7791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2016
Last Update Date	:	09/13/2016

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