Provider Demographics
NPI:1245209808
Name:HEISSERER, MEGGEN SMILEY
Entity Type:Individual
Prefix:MRS
First Name:MEGGEN
Middle Name:SMILEY
Last Name:HEISSERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGGEN
Other - Middle Name:BETH
Other - Last Name:SMILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8650
Mailing Address - Country:US
Mailing Address - Phone:972-724-2400
Mailing Address - Fax:972-724-2495
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-442-8600
Practice Address - Fax:817-442-8603
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1142198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist