Provider Demographics
NPI:1093938839
Name:HEENAN, KELLY L (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:HEENAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:BACKHAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3741 ARROYO DRIVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604
Mailing Address - Country:US
Mailing Address - Phone:307-472-2995
Mailing Address - Fax:
Practice Address - Street 1:3741 ARROYO DRIVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604
Practice Address - Country:US
Practice Address - Phone:307-472-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62396101YP2500X
WYLPC - 1073101YP2500X
TX201042106H00000X
WYLMFT -139106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional