Provider Demographics
NPI:1194826479
Name:HEINZELMAN, KEITH RONALD (DPT, CHT, MTC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:RONALD
Last Name:HEINZELMAN
Suffix:
Gender:M
Credentials:DPT, CHT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 MADISON AVE N
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1768
Mailing Address - Country:US
Mailing Address - Phone:206-855-8455
Mailing Address - Fax:206-855-8465
Practice Address - Street 1:563 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1768
Practice Address - Country:US
Practice Address - Phone:206-855-8455
Practice Address - Fax:206-855-8465
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2251H1200X
WAPT00008747225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8450744Medicaid
WA8450744Medicaid