Provider Demographics
NPI:1619412889
Name:HEIM, KYLIE (ATC)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:HEIM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W ALDRICH RD APT 8
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2770
Mailing Address - Country:US
Mailing Address - Phone:417-693-2459
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2578
Practice Address - Country:US
Practice Address - Phone:417-328-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130220762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013022076OtherMISSOURI LICENSE