Provider Demographics
NPI:1376733360
Name:DEFOREEST, HEATHER ANN (RPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:DEFOREEST
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-1602
Mailing Address - Country:US
Mailing Address - Phone:316-681-3204
Mailing Address - Fax:
Practice Address - Street 1:4921 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-1602
Practice Address - Country:US
Practice Address - Phone:316-681-3204
Practice Address - Fax:316-681-0541
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200316360BMedicaid
KS115161OtherBLUE CROSS BLUE SHIELD