Provider Demographics
NPI:1164571576
Name:HEITKEMPER, THOMAS WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:HEITKEMPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 YANKEE PARK PL
Mailing Address - Street 2:STE A
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1868
Mailing Address - Country:US
Mailing Address - Phone:937-439-4949
Mailing Address - Fax:937-439-4948
Practice Address - Street 1:1550 YANKEE PARK PL
Practice Address - Street 2:STE A
Practice Address - City:CENTERVILLE FINANCE
Practice Address - State:OH
Practice Address - Zip Code:45458-1868
Practice Address - Country:US
Practice Address - Phone:937-439-4949
Practice Address - Fax:937-439-4948
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0934261Medicaid
OH0934261Medicaid
OHHECP19281Medicare PIN