Provider Demographics
NPI:1417775404
Name:HEACOCK, KIMBERLY SUE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:HEACOCK
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 1:2002 GOLDMILLER RD
Mailing Address - Street 2:
Mailing Address - City:BUNKER HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25413-3571
Mailing Address - Country:US
Mailing Address - Phone:304-596-7792
Mailing Address - Fax:
Practice Address - Street 1:2002 GOLDMILLER RD
Practice Address - Street 2:
Practice Address - City:BUNKER HILL
Practice Address - State:WV
Practice Address - Zip Code:25413-3571
Practice Address - Country:US
Practice Address - Phone:304-596-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency