Provider Demographics
NPI:1124241088
Name:HEIDEGGER, DIANE KAY (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KAY
Last Name:HEIDEGGER
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 1:484 LENNOX DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5134
Mailing Address - Country:US
Mailing Address - Phone:832-257-4154
Mailing Address - Fax:
Practice Address - Street 1:111 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-4853
Practice Address - Country:US
Practice Address - Phone:832-257-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1075919225100000X
NCCP018927T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCP018927TOtherPHYSICAL THERAPY LICENSE