Provider Demographics
NPI:1295038511
Name:HARRELL, HEIDI SUE (PT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUE
Last Name:HARRELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1381 TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8705
Mailing Address - Country:US
Mailing Address - Phone:269-921-2890
Mailing Address - Fax:269-428-2535
Practice Address - Street 1:1381 TIMBERLANE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8705
Practice Address - Country:US
Practice Address - Phone:269-921-2890
Practice Address - Fax:269-428-2535
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist