Provider Demographics
NPI:1578022380
Name:HERITIER, KIMBERLY SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:HERITIER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 E COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48634-9404
Mailing Address - Country:US
Mailing Address - Phone:989-737-3602
Mailing Address - Fax:
Practice Address - Street 1:1583 E COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:MI
Practice Address - Zip Code:48634-9404
Practice Address - Country:US
Practice Address - Phone:989-737-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001112225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant