Provider Demographics
NPI:1710210604
Name:HEITZ, KOURTNEY (PT)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:HEITZ
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 1:4273 KEATON CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8220
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:636-422-1051
Practice Address - Street 1:118 RICHARDSON XING
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6023
Practice Address - Country:US
Practice Address - Phone:636-206-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO991511002Medicare PIN
MO991509002Medicare PIN