Provider Demographics
NPI:1952900334
Name:HEISSE, NICHOLAS (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HEISSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 MEMORIAL DR UNIT 2609
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-2647
Mailing Address - Country:US
Mailing Address - Phone:314-650-9074
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR # 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:817-550-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1338629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist