Provider Demographics
NPI:1033398300
Name:HANSEN, HEATH
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9009B INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2502
Practice Address - Country:US
Practice Address - Phone:219-923-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225500000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622333OtherBLUE CROSS BLUE SHIELD
IN7454077OtherAETNA
IN01622333OtherBLUE CROSS BLUE SHIELD