Provider Demographics
NPI:1477869576
Name:THIESSEN, HEATHER R (AT, PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:AT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE
Mailing Address - Street 2:STE 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3013
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-2300
Practice Address - Country:US
Practice Address - Phone:620-241-4201
Practice Address - Fax:620-241-4210
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01324225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant