Provider Demographics
NPI:1548515000
Name:SULICK, HEIDI (PTA)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:SULICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OLD BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4906
Mailing Address - Country:US
Mailing Address - Phone:912-450-6203
Mailing Address - Fax:
Practice Address - Street 1:3 OLD BRIDGE DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4906
Practice Address - Country:US
Practice Address - Phone:912-450-6203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2261225200000X
SC1917225200000X
NC2291225200000X
TX2033959225200000X
LA1914225200000X
VA1450225200000X
MDH2036225200000X
FL23361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant