Provider Demographics
NPI:1104861327
Name:HEISDORF, MAKENZIE ALYCE (DPT)
Entity Type:Individual
Prefix:DR
First Name:MAKENZIE
Middle Name:ALYCE
Last Name:HEISDORF
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MAKENZIE
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:653 CAMINO DE LOS MARES STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2808
Mailing Address - Country:US
Mailing Address - Phone:949-496-0122
Mailing Address - Fax:949-496-5027
Practice Address - Street 1:653 CAMINO DE LOS MARES STE 110
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-496-0122
Practice Address - Fax:949-496-5027
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT27882 AMedicare ID - Type Unspecified