Provider Demographics
NPI:1407313406
Name:HEINE, COURTNEY RAE (RD, LD, CMHIMP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:RAE
Last Name:HEINE
Suffix:
Gender:F
Credentials:RD, LD, CMHIMP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:RAE
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:884 ACID MINE RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:884 ACID MINE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2695
Practice Address - Country:US
Practice Address - Phone:573-619-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014012347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered