Provider Demographics
NPI:1366923484
Name:HEINICKE, IAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:HEINICKE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 NIAGARA DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:MI
Mailing Address - Zip Code:49065-9532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23211 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9701
Practice Address - Country:US
Practice Address - Phone:269-668-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist