Provider Demographics
NPI:1639242514
Name:HEASLEY, JANET DELORES (DO)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:DELORES
Last Name:HEASLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 EVERGREEN RDG
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9746
Mailing Address - Country:US
Mailing Address - Phone:248-627-5066
Mailing Address - Fax:248-627-7685
Practice Address - Street 1:380 MILL ST
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8721
Practice Address - Country:US
Practice Address - Phone:248-627-7682
Practice Address - Fax:248-627-7685
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010131192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114139715Medicaid
MI114139715Medicaid
MIOM83710Medicare ID - Type Unspecified