Provider Demographics
NPI:1144384652
Name:BLUE HERON PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:BLUE HERON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:SAWERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-947-7039
Mailing Address - Street 1:3708 E RIPPLE RD
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-8102
Mailing Address - Country:US
Mailing Address - Phone:212-947-7039
Mailing Address - Fax:
Practice Address - Street 1:3708 E RIPPLE RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-8102
Practice Address - Country:US
Practice Address - Phone:212-947-7039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108378Medicare PIN