Provider Demographics
NPI:1093916058
Name:CHURCH, HEIDI LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:LYNN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23746 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9097
Mailing Address - Country:US
Mailing Address - Phone:313-590-4652
Mailing Address - Fax:
Practice Address - Street 1:729 W ANN ARBOR TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1631
Practice Address - Country:US
Practice Address - Phone:734-414-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant