Provider Demographics
NPI:1336611524
Name:HEITKAMP, KELLY MARIE (LISW-S, TRCC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:HEITKAMP
Suffix:
Gender:F
Credentials:LISW-S, TRCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6645 PRINCETON GLENDALE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TWP
Practice Address - State:OH
Practice Address - Zip Code:45011-7547
Practice Address - Country:US
Practice Address - Phone:859-322-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0387182Medicaid