Provider Demographics
NPI:1588950448
Name:HEATON, ANGELA M (PT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:HEATON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:BORNHORST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:253 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MINSTER
Mailing Address - State:OH
Mailing Address - Zip Code:45865-1077
Mailing Address - Country:US
Mailing Address - Phone:419-501-2165
Mailing Address - Fax:419-501-2166
Practice Address - Street 1:253 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-1077
Practice Address - Country:US
Practice Address - Phone:419-501-2165
Practice Address - Fax:419-501-2166
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT005364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2781431Medicaid