Provider Demographics
NPI:1124170121
Name:HECKEL, MARY M (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:HECKEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4488 YORGASON WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3146
Mailing Address - Country:US
Mailing Address - Phone:208-859-9953
Mailing Address - Fax:208-629-3155
Practice Address - Street 1:448 S MAPLE GROVE ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-859-9953
Practice Address - Fax:208-629-3155
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTA484OtherBLUE CROSS OF IDAHO
ID000010148543OtherREGENCE BLUE SHIELD OF ID
ID000010148543OtherREGENCE BLUE SHIELD OF ID