Provider Demographics
NPI:1912132317
Name:HEATON, TERENCE (PT)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:
Last Name:HEATON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E MAIN ST
Mailing Address - Street 2:STE. B
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1681
Mailing Address - Country:US
Mailing Address - Phone:248-349-9339
Mailing Address - Fax:248-349-9342
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:STE. B
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1681
Practice Address - Country:US
Practice Address - Phone:248-349-9339
Practice Address - Fax:248-349-9342
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H25093OtherBLUE CROSS BLUE SHIELD MI
MIN82620015Medicare PIN