Provider Demographics
NPI:1275634354
Name:WELCH, HEIDI MARIE (PT, ATC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:WELCH
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:MARIE
Other - Last Name:MOENING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, ATC
Mailing Address - Street 1:32 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-4903
Mailing Address - Country:US
Mailing Address - Phone:641-753-6636
Mailing Address - Fax:641-753-1005
Practice Address - Street 1:32 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-4903
Practice Address - Country:US
Practice Address - Phone:641-753-6636
Practice Address - Fax:641-753-1005
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10527225100000X
IA004721225100000X
WI645-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40472000Medicaid
WI005983450Medicare ID - Type Unspecified