Provider Demographics
NPI:1932180288
Name:HEISTAND, CHRISTOPHER P (SLP)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:P
Last Name:HEISTAND
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MARVIN RD NE
Mailing Address - Street 2:307 #266
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5749
Mailing Address - Country:US
Mailing Address - Phone:360-786-1753
Mailing Address - Fax:360-786-1793
Practice Address - Street 1:4510 INTELCO LOOP SE
Practice Address - Street 2:STE. B
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6004
Practice Address - Country:US
Practice Address - Phone:360-786-1753
Practice Address - Fax:360-786-1793
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125396Medicaid
WA5319HEOtherREGENCE BLUE SHIELD