Provider Demographics
NPI:1548586316
Name:HEINEMAN, THERESA OMOLOLA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:OMOLOLA
Last Name:HEINEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:OMOLOLA
Other - Last Name:BELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8320 CITY CENTRE DR
Mailing Address - Street 2:SUITE G.
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3382
Mailing Address - Country:US
Mailing Address - Phone:651-738-9888
Mailing Address - Fax:651-738-9889
Practice Address - Street 1:8320 CITY CENTRE DR
Practice Address - Street 2:SUITE G.
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3382
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103873225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics