Provider Demographics
NPI:1043987795
Name:HEAVENS, IMARI JEANINE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:IMARI
Middle Name:JEANINE
Last Name:HEAVENS
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12731 MARBLESTONE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8334
Mailing Address - Country:US
Mailing Address - Phone:571-659-2612
Mailing Address - Fax:
Practice Address - Street 1:12731 MARBLESTONE DR STE 202
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8334
Practice Address - Country:US
Practice Address - Phone:571-659-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic