Provider Demographics
NPI:1003537515
Name:HEARON, KIMBERLY EVETTE
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:EVETTE
Last Name:HEARON
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 1:5971 WINCHESTER PL
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4915
Mailing Address - Country:US
Mailing Address - Phone:219-201-0716
Mailing Address - Fax:
Practice Address - Street 1:5971 WINCHESTER PL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4915
Practice Address - Country:US
Practice Address - Phone:219-201-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000043A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)