Provider Demographics
NPI:1578692190
Name:HEATH, GERWYN EVANS (LPA)
Entity Type:Individual
Prefix:MR
First Name:GERWYN
Middle Name:EVANS
Last Name:HEATH
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 ACADEMY ST S
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-2451
Mailing Address - Country:US
Mailing Address - Phone:252-332-2540
Mailing Address - Fax:252-332-2540
Practice Address - Street 1:226 ACADEMY ST S
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-2451
Practice Address - Country:US
Practice Address - Phone:252-332-2540
Practice Address - Fax:252-332-2540
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1197101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107378Medicaid