Provider Demographics
NPI:1285764753
Name:HEITMANN, TYRONE DOMINIC (PT)
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:DOMINIC
Last Name:HEITMANN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 WAPLES MILL RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6078
Mailing Address - Country:US
Mailing Address - Phone:703-383-6454
Mailing Address - Fax:703-810-5494
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 100A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-810-5227
Practice Address - Fax:703-810-5224
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist