Provider Demographics
NPI:1558859462
Name:KACOS, HEATHER N (PSYD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:N
Last Name:KACOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10770 N 46TH ST BLDG E
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-3442
Mailing Address - Country:US
Mailing Address - Phone:813-631-7123
Mailing Address - Fax:813-631-7130
Practice Address - Street 1:10770 N 46TH ST BLDG E
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-3442
Practice Address - Country:US
Practice Address - Phone:813-631-2517
Practice Address - Fax:813-631-7130
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10087103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty