Provider Demographics
NPI:1518014174
Name:HEIDT, MICHAEL JOHN (LAT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:HEIDT
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 THUNDER RD
Mailing Address - Street 2:
Mailing Address - City:WHITELAW
Mailing Address - State:WI
Mailing Address - Zip Code:54247-9694
Mailing Address - Country:US
Mailing Address - Phone:920-794-5166
Mailing Address - Fax:
Practice Address - Street 1:5000 MEMORIAL DR
Practice Address - Street 2:REHABILITATION DEPARTMENT
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3900
Practice Address - Country:US
Practice Address - Phone:920-794-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer