Provider Demographics
NPI:1376394312
Name:HEITSCH, EMILY GRACE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:HEITSCH
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 1:934 FAIRMOUNT ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1507
Mailing Address - Country:US
Mailing Address - Phone:989-763-4838
Mailing Address - Fax:
Practice Address - Street 1:934 FAIRMOUNT ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1507
Practice Address - Country:US
Practice Address - Phone:989-763-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704344956390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program