Provider Demographics
NPI:1114185816
Name:SHAH, HEATHER RENAE (PT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RENAE
Last Name:SHAH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:RENAE
Other - Last Name:BOLLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5810 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1566
Mailing Address - Country:US
Mailing Address - Phone:619-787-5819
Mailing Address - Fax:
Practice Address - Street 1:3000 CENTERPOINT PKWY
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-3116
Practice Address - Country:US
Practice Address - Phone:248-857-6776
Practice Address - Fax:248-857-7102
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000146906225100000X
MI5501015693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist