Provider Demographics
NPI:1033137757
Name:HEERINGA, MICAH L (MPT)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:L
Last Name:HEERINGA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:888-700-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:1405 E EDISON AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1622
Practice Address - Country:US
Practice Address - Phone:509-837-7400
Practice Address - Fax:509-837-5068
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8424673Medicaid
WAQ50868Medicare UPIN
WA8424673Medicaid