Provider Demographics
NPI:1568819423
Name:LYLES, HEATHER SUE (PT, DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:SUE
Last Name:LYLES
Suffix:
Gender:F
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1508 N THORNTON AVE
Practice Address - Street 2:STE 106
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8516
Practice Address - Country:US
Practice Address - Phone:706-226-0816
Practice Address - Fax:706-226-9584
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist