Provider Demographics
NPI:1427269505
Name:HEATON, GWENDOLYN MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MICHELLE
Last Name:HEATON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:HEATON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:6151 DEW DR.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3917
Mailing Address - Country:US
Mailing Address - Phone:915-587-4081
Mailing Address - Fax:
Practice Address - Street 1:1891 N LEE TREVINO DR
Practice Address - Street 2:SUITE 700
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4127
Practice Address - Country:US
Practice Address - Phone:915-593-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1156168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456749Medicare ID - Type Unspecified