Provider Demographics
NPI:1336187905
Name:HEIDT KOZISEK, ELIZABETH ANN (PH D)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:HEIDT KOZISEK
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:HEIDT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH D
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:ST. LIBORY
Mailing Address - State:NE
Mailing Address - Zip Code:68872-0065
Mailing Address - Country:US
Mailing Address - Phone:308-379-1949
Mailing Address - Fax:308-687-6309
Practice Address - Street 1:1932 ASPEN CIRCLE
Practice Address - Street 2:SUITE J
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68802
Practice Address - Country:US
Practice Address - Phone:308-379-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE451103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$-26Medicaid
NE$$$$$$$$$26Medicaid
NE271251Medicare PIN