Provider Demographics
NPI:1396034880
Name:HEITZMAN, HOLLY A (LATC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:HEITZMAN
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E 81ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2680
Mailing Address - Country:US
Mailing Address - Phone:317-370-0923
Mailing Address - Fax:
Practice Address - Street 1:8227 NORTHWEST BLVD
Practice Address - Street 2:STE.160
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1387
Practice Address - Country:US
Practice Address - Phone:317-415-5747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000330A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer