Provider Demographics
NPI:1134493067
Name:HEISTAD, PHILLIP NORMAN
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:NORMAN
Last Name:HEISTAD
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 1:1226 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54491-9750
Mailing Address - Country:US
Mailing Address - Phone:715-882-8107
Mailing Address - Fax:
Practice Address - Street 1:1226 LAKE ST
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54491-9750
Practice Address - Country:US
Practice Address - Phone:715-882-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI237700000X237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter