Provider Demographics
NPI:1598577074
Name:HEINZ, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HEINZ
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 1:509 HUNT AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3538
Mailing Address - Country:US
Mailing Address - Phone:307-670-1648
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD STE 1004
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6349
Practice Address - Country:US
Practice Address - Phone:307-363-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1522101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional