Provider Demographics
NPI:1447224803
Name:PAULSON, HEIDI JO (MSPT, DPT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:PAULSON
Suffix:
Gender:F
Credentials:MSPT, DPT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:PENNYPACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:7141 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1811
Mailing Address - Country:US
Mailing Address - Phone:443-663-6490
Mailing Address - Fax:443-663-6003
Practice Address - Street 1:202 COURSEVALL DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-2804
Practice Address - Country:US
Practice Address - Phone:410-758-0018
Practice Address - Fax:410-758-4031
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61826Medicare UPIN
MDKM25N279Medicare ID - Type Unspecified