Provider Demographics
NPI:1306328596
Name:HEINZE, KELLY C
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:C
Last Name:HEINZE
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 1:1201 45TH AVE NW LOT 3
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:ND
Mailing Address - Zip Code:58540-9420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:ND
Practice Address - Zip Code:58540-7168
Practice Address - Country:US
Practice Address - Phone:701-463-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1661235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist