Provider Demographics
NPI:1326114687
Name:HEINECKE, GAIL M (PT)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:M
Last Name:HEINECKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 KREUSER RDG
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9793
Mailing Address - Country:US
Mailing Address - Phone:262-628-1712
Mailing Address - Fax:
Practice Address - Street 1:6800 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-5002
Practice Address - Country:US
Practice Address - Phone:414-353-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1857-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40011900Medicaid