Provider Demographics
NPI:1891965513
Name:CHRISTOPHER HEISTAND SLP, INC. PS
Entity Type:Organization
Organization Name:CHRISTOPHER HEISTAND SLP, INC. PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:HEISTAND
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:360-786-1753
Mailing Address - Street 1:4820 YELM HWY SE STE B
Mailing Address - Street 2:PMB 210
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4904
Mailing Address - Country:US
Mailing Address - Phone:360-786-1753
Mailing Address - Fax:360-786-1793
Practice Address - Street 1:4531 INTELCO LOOP SE
Practice Address - Street 2:SUITE 3
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5941
Practice Address - Country:US
Practice Address - Phone:360-786-1753
Practice Address - Fax:360-786-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125396Medicaid