Provider Demographics
NPI:1316177637
Name:BANIAK, HEATHER E (PT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:BANIAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:E
Other - Last Name:SCHAEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:636-356-5001
Practice Address - Street 1:2454 WEST CLAY
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2548
Practice Address - Country:US
Practice Address - Phone:636-949-3926
Practice Address - Fax:636-949-3928
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009020457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01170364OtherRAILROAD MEDICARE
MO12480681OtherCAQH
MO12480681OtherCAQH
MOP01170364OtherRAILROAD MEDICARE