Provider Demographics
NPI:1538650981
Name:HEATLAND PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:HEATLAND PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-523-9033
Mailing Address - Street 1:524 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-1536
Mailing Address - Country:US
Mailing Address - Phone:616-523-9033
Mailing Address - Fax:
Practice Address - Street 1:524 W MAIN ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846
Practice Address - Country:US
Practice Address - Phone:616-522-7183
Practice Address - Fax:616-523-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009002103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty