Provider Demographics
NPI:1871068163
Name:HEITZ, KRISTINA ELLEN (PHYSICAL THERAPY)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ELLEN
Last Name:HEITZ
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:ELLEN
Other - Last Name:HICKENBOTTOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1175 BEVERLY PIKE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-9759
Mailing Address - Country:US
Mailing Address - Phone:304-636-1391
Mailing Address - Fax:304-636-1138
Practice Address - Street 1:1175 BEVERLY PIKE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-9759
Practice Address - Country:US
Practice Address - Phone:304-636-1391
Practice Address - Fax:304-636-1138
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT004015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist