Provider Demographics
NPI:1376155424
Name:HEADING, KODIE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KODIE
Middle Name:
Last Name:HEADING
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 OLDS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-1319
Mailing Address - Country:US
Mailing Address - Phone:231-384-1308
Mailing Address - Fax:
Practice Address - Street 1:2505 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2635
Practice Address - Country:US
Practice Address - Phone:574-855-1732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst