Provider Demographics
NPI:1346233509
Name:BARRY, HEATHER M (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:BARRY
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 E SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5907
Practice Address - Country:US
Practice Address - Phone:414-223-2727
Practice Address - Fax:414-223-2724
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5801024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36146600Medicaid
WI000480096Medicare PIN
WI000480094Medicare PIN
WIK400154429Medicare PIN
WIP00463008Medicare PIN
WI830420054Medicare PIN
WI830420020Medicare PIN
WI36146600Medicaid