Provider Demographics
NPI:1053781450
Name:HEIMBUCH, KARLY
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:
Last Name:HEIMBUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20212 AUTUMN FERN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2914
Mailing Address - Country:US
Mailing Address - Phone:732-977-1478
Mailing Address - Fax:
Practice Address - Street 1:2909 MANSFIELD BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-6931
Practice Address - Country:US
Practice Address - Phone:732-977-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025182255A2300X
FLAL61932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer