Provider Demographics
NPI:1063583656
Name:HEITZMANN, DENNIS E (PHD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:E
Last Name:HEITZMANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S ALLEN ST
Mailing Address - Street 2:218
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4849
Mailing Address - Country:US
Mailing Address - Phone:814-234-3010
Mailing Address - Fax:814-234-2170
Practice Address - Street 1:315 S ALLEN ST
Practice Address - Street 2:218
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4849
Practice Address - Country:US
Practice Address - Phone:814-234-3010
Practice Address - Fax:814-234-2170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004520-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA448987Medicare ID - Type UnspecifiedMEDICARE