MEDICARE: MRS. KAYLEIGH HEISE PTA

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	225200000X	Physical Therapy Assistant	001889	WV

General Provider Information

NPI Number	:	1952911927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAYLEIGH HEISE PTA

Provider Business Mailing Address
First Line	:	40 COMMERCE DR STE 101
Second Line	:
City	:	WESTOVER
State	:	WV
Zip	:	26501-3952
Country	:	US
Telephone Number	:	304-292-7535
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 COMMERCE DR STE 101
Second Line	:
City	:	WESTOVER
State	:	WV
Zip	:	26501-3952
Country	:	US
Telephone Number	:	304-292-7535
Fax Number	:

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

Provider Enumeration Date	:	08/05/2020
Last Update Date	:	08/05/2020

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