Provider Demographics
NPI:1710186507
Name:HEISKALA, KEVIN RAY (MSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RAY
Last Name:HEISKALA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5852
Mailing Address - Country:US
Mailing Address - Phone:301-791-3045
Mailing Address - Fax:240-313-3071
Practice Address - Street 1:1180 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5852
Practice Address - Country:US
Practice Address - Phone:301-791-3045
Practice Address - Fax:240-313-3071
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical