Provider Demographics
NPI:1609998343
Name:FLYNN, HEATHER M (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:FLYNN
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 1:143 E POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:IL
Mailing Address - Zip Code:61028-9761
Mailing Address - Country:US
Mailing Address - Phone:815-858-3783
Mailing Address - Fax:
Practice Address - Street 1:653 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5005
Practice Address - Country:US
Practice Address - Phone:815-232-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08932005OtherBCBS PROVIDER #
IL208991Medicare ID - Type UnspecifiedGROUP NUMBER
ILK13034Medicare PIN