Provider Demographics
NPI:1083614556
Name:HEGSTROM, MARY JO (PT, BSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:HEGSTROM
Suffix:
Gender:F
Credentials:PT, BSPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:BUGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:6640 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2617
Practice Address - Country:US
Practice Address - Phone:913-384-5810
Practice Address - Fax:913-384-0719
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-00540225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2868029OtherMEDICARE PTAN
MOMA4370009OtherMEDICARE PTAN
34386032OtherBCBS KC
KST66E310OtherMEDICARE B - KS