Provider Demographics
NPI:1265917686
Name:HEADING, KACIE DANIELLE (LLMSW)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:DANIELLE
Last Name:HEADING
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MRS
Other - First Name:KACIE
Other - Middle Name:DANIELLE
Other - Last Name:BERTHELOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLMSW
Mailing Address - Street 1:12719 S WEST BAY SHORE DR STE 9
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5489
Mailing Address - Country:US
Mailing Address - Phone:231-943-1031
Mailing Address - Fax:
Practice Address - Street 1:12719 S. WEST BAY SHORE DRIVE
Practice Address - Street 2:SUITE 9
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-943-1031
Practice Address - Fax:231-943-1032
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011034311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical