Provider Demographics
NPI:1235647686
Name:HEATHMON, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:HEATHMON
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 1:3440 E RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2201
Mailing Address - Country:US
Mailing Address - Phone:702-214-4212
Mailing Address - Fax:
Practice Address - Street 1:3440 E RUSSELL RD # 212
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2201
Practice Address - Country:US
Practice Address - Phone:702-712-3617
Practice Address - Fax:702-712-3617
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst