Provider Demographics
NPI:1326252370
Name:HEITZKEY, KELLIE MARIE (MS-CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MARIE
Last Name:HEITZKEY
Suffix:
Gender:F
Credentials:MS-CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N70W5474 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2110
Mailing Address - Country:US
Mailing Address - Phone:262-618-4053
Mailing Address - Fax:
Practice Address - Street 1:3431 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-2938
Practice Address - Country:US
Practice Address - Phone:920-457-5046
Practice Address - Fax:920-457-4753
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2422-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42560800Medicaid