Provider Demographics
NPI:1518905017
Name:HEITKAMP, GERALYN M (OTR/L)
Entity Type:Individual
Prefix:
First Name:GERALYN
Middle Name:M
Last Name:HEITKAMP
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 COUNTY ROAD 3
Mailing Address - Street 2:
Mailing Address - City:KINDRED
Mailing Address - State:ND
Mailing Address - Zip Code:58051-9523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 25TH ST S
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-280-2212
Practice Address - Fax:701-271-1023
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND465225X00000X
MN101537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND23268Medicare PIN