Basic Information
| Provider Information | |||||||||
| NPI: | 1558885491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 SOUTH | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300523918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401F PULASKI HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4433725300 | ||||||||
| FaxNumber: | 4433725810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT026258 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 26851 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.