Provider Demographics
NPI:1255742854
Name:HEINZ, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HEINZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE BLDG 5
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1282
Mailing Address - Country:US
Mailing Address - Phone:859-233-0444
Mailing Address - Fax:859-225-6027
Practice Address - Street 1:1351 NEWTOWN PIKE BLDG 5
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1282
Practice Address - Country:US
Practice Address - Phone:859-233-0444
Practice Address - Fax:859-225-6027
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1081753163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid