Provider Demographics
NPI:1750318259
Name:HEINTZELMAN, KENT JOHN (LCSW LSATP)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:JOHN
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:LCSW LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:VA. BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-664-6670
Mailing Address - Fax:757-664-6678
Practice Address - Street 1:4460 CORPORATION LANE
Practice Address - Street 2:
Practice Address - City:VA. BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2978
Practice Address - Country:US
Practice Address - Phone:757-664-6670
Practice Address - Fax:757-664-6678
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040033981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008902178Medicaid
VA008902178Medicaid