Provider Demographics
NPI:1720331184
Name:ROEDER, HEATHER ARLENE (PT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ARLENE
Last Name:ROEDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:ARLENE
Other - Last Name:DECLERCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 NW 9TH AVE
Mailing Address - Street 2:MERCER COUNTY HOSPITAL
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1258
Mailing Address - Country:US
Mailing Address - Phone:309-582-5301
Mailing Address - Fax:309-582-3797
Practice Address - Street 1:409 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1258
Practice Address - Country:US
Practice Address - Phone:309-582-5301
Practice Address - Fax:309-582-3797
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.015946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL366007544001Medicaid
IL36007544401Medicaid
IL366007544001Medicaid
IL142304Medicare PIN
IL141304Medicare PIN
IL142304Medicare Oscar/Certification