Provider Demographics
NPI:1467556589
Name:HEINRICHS, KENNETH E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:HEINRICHS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E MCARDLE DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1717
Mailing Address - Country:US
Mailing Address - Phone:815-342-7181
Mailing Address - Fax:815-344-9795
Practice Address - Street 1:755 E. MCARDLE DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1717
Practice Address - Country:US
Practice Address - Phone:815-342-7181
Practice Address - Fax:815-344-9795
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006063103TC0700X
WI2384057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
206413Medicare ID - Type UnspecifiedPROVIDER NO