Provider Demographics
NPI:1285658559
Name:HEITZMAN-POWELL, LINDA (PHD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:HEITZMAN-POWELL
Suffix:
Gender:F
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:PO BOX 252
Mailing Address - Street 2:304 WEST STREET
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-0252
Mailing Address - Country:US
Mailing Address - Phone:913-471-7061
Mailing Address - Fax:913-471-7062
Practice Address - Street 1:304 WEST ST
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-9714
Practice Address - Country:US
Practice Address - Phone:913-471-7061
Practice Address - Fax:913-471-7062
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP1216103TB0200X
1-01-0627103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS00118206OtherBLUE CROSS BLUE SHIELD
KS100640840Medicaid