Provider Demographics
NPI:1710409917
Name:HEASLEY, KRISTINE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:HEASLEY
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 1:511 EASTVIEW TERRACE
Mailing Address - Street 2:APT. 2
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009
Mailing Address - Country:US
Mailing Address - Phone:732-608-4506
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1905
Practice Address - Country:US
Practice Address - Phone:214-442-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4683225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant