Provider Demographics
NPI:1801174610
Name:LYNDE, HEATHER JEAN (PTA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:LYNDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JEAN
Other - Last Name:HAENITSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:129 W 4TH ST
Mailing Address - Street 2:P.O.BOX 493
Mailing Address - City:PECATONICA
Mailing Address - State:IL
Mailing Address - Zip Code:61063-7712
Mailing Address - Country:US
Mailing Address - Phone:815-990-5641
Mailing Address - Fax:
Practice Address - Street 1:129 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-7712
Practice Address - Country:US
Practice Address - Phone:815-990-5641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005277225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant