Provider Demographics
NPI:1689961450
Name:HEITHAUS, MITZI ANN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MITZI
Middle Name:ANN
Last Name:HEITHAUS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-0861
Mailing Address - Country:US
Mailing Address - Phone:870-480-7017
Mailing Address - Fax:
Practice Address - Street 1:400 EAST 10TH STREET
Practice Address - Street 2:
Practice Address - City:GREEN FOREST
Practice Address - State:AR
Practice Address - Zip Code:72638-0000
Practice Address - Country:US
Practice Address - Phone:870-480-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist