Provider Demographics
NPI:1700221777
Name:HEINEMANN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HEINEMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 PROSPECT PARK W
Mailing Address - Street 2:1R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6669
Mailing Address - Country:US
Mailing Address - Phone:708-638-0155
Mailing Address - Fax:
Practice Address - Street 1:2121 NEWMARKET PKWY SE STE 130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9309
Practice Address - Country:US
Practice Address - Phone:678-486-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-05
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY372809091252Y00000X
GA11622943103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No252Y00000XAgenciesEarly Intervention Provider Agency