Basic Information
| Provider Information | |||||||||
| NPI: | 1710210604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEITZ | ||||||||
| FirstName: | KOURTNEY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4273 KEATON CROSSING BLVD | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633688220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362064225 | ||||||||
| FaxNumber: | 6364221051 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 RICHARDSON XING | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630106023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362064146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2009034737 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.