Provider Demographics
NPI:1619934478
Name:HEIM, MARTY NELSON (PTA, ATC-L)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:NELSON
Last Name:HEIM
Suffix:
Gender:M
Credentials:PTA, ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 MONTEGO PL
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5092
Mailing Address - Country:US
Mailing Address - Phone:801-440-3228
Mailing Address - Fax:
Practice Address - Street 1:5430 S 1900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2991
Practice Address - Country:US
Practice Address - Phone:801-779-9975
Practice Address - Fax:801-779-2330
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5405724-48102255A2300X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer