Provider Demographics
NPI:1972806479
Name:HEITCHUE, MARK JOSEPH (MPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:HEITCHUE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W BIG BEAVER RD STE 125
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3915
Mailing Address - Country:US
Mailing Address - Phone:248-309-8900
Mailing Address - Fax:
Practice Address - Street 1:60 W BIG BEAVER RD STE 125
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3915
Practice Address - Country:US
Practice Address - Phone:248-309-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist