Provider Demographics
NPI:1467668285
Name:HEENAN, THERESE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:HEENAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23120 N LAGRANGE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-7760
Mailing Address - Country:US
Mailing Address - Phone:815-464-5440
Mailing Address - Fax:815-936-5404
Practice Address - Street 1:23120 N LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-7760
Practice Address - Country:US
Practice Address - Phone:815-464-5440
Practice Address - Fax:815-936-5404
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL81500295OtherMEDICAID
IN000000688021OtherANTHEM
IN9681438OtherAETNA
IN200760IMedicare PIN
IL81500295OtherMEDICAID