Provider Demographics
NPI:1629515184
Name:HEINEN, STACY (PT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HEINEN
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 1:1900 W 75TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3502
Mailing Address - Country:US
Mailing Address - Phone:913-432-3950
Mailing Address - Fax:913-432-3948
Practice Address - Street 1:1900 W 75TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-3502
Practice Address - Country:US
Practice Address - Phone:913-432-3950
Practice Address - Fax:913-432-3948
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03748225100000X
MO2004018044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist