Provider Demographics
NPI:1841701893
Name:GILLIS, HEIDI LOUISA (PTA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LOUISA
Last Name:GILLIS
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 1:1132 HIGHVIEW LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2222
Mailing Address - Country:US
Mailing Address - Phone:920-562-0621
Mailing Address - Fax:
Practice Address - Street 1:958 FOOTE ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:WI
Practice Address - Zip Code:54165-1044
Practice Address - Country:US
Practice Address - Phone:920-562-0621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2708-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant