Provider Demographics
NPI:1326718206
Name:HEIMBACH, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:HEIMBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 KING RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-1428
Mailing Address - Country:US
Mailing Address - Phone:810-328-4500
Mailing Address - Fax:
Practice Address - Street 1:3104 KING RD
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-1428
Practice Address - Country:US
Practice Address - Phone:810-328-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669706149Medicaid