Provider Demographics
NPI:1104301589
Name:EHLER, HEIDI SUSANNA (PTA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUSANNA
Last Name:EHLER
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 1:1017 KONETZKE LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-4384
Mailing Address - Country:US
Mailing Address - Phone:979-220-7751
Mailing Address - Fax:
Practice Address - Street 1:457 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1937
Practice Address - Country:US
Practice Address - Phone:979-968-5865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2139127225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant