Provider Demographics
NPI:1952414906
Name:HEYDENBURG, TINA LOUISE (PT)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:LOUISE
Last Name:HEYDENBURG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:LOUISE
Other - Last Name:HEYDENBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-236-2774
Mailing Address - Fax:706-236-2783
Practice Address - Street 1:1897 ISLAND WALK WAY
Practice Address - Street 2:UNIT 5
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1948
Practice Address - Country:US
Practice Address - Phone:904-261-4664
Practice Address - Fax:904-261-5852
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 16749225100000X
CO9844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist