Provider Demographics
NPI:1558696245
Name:ILAN, HEIDI ANNE REYES (PT)
Entity Type:Individual
Prefix:
First Name:HEIDI ANNE
Middle Name:REYES
Last Name:ILAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 TOWNSEND DR
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3983
Mailing Address - Country:US
Mailing Address - Phone:707-319-4865
Mailing Address - Fax:
Practice Address - Street 1:2160 APPIAN WAY STE 101
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2524
Practice Address - Country:US
Practice Address - Phone:510-724-1248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist