Provider Demographics
NPI:1396508743
Name:BANIS, HEATHER (PTA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BANIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-4519
Mailing Address - Country:US
Mailing Address - Phone:630-967-2000
Mailing Address - Fax:
Practice Address - Street 1:860 VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-4519
Practice Address - Country:US
Practice Address - Phone:630-967-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009555225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant