Provider Demographics
NPI:1336611524
Name:HEITKAMP, KELLY MARIE (LISW-S, TRCC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:HEITKAMP
Suffix:
Gender:F
Credentials:LISW-S, TRCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7469 CINNAMON WOODS DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1041
Mailing Address - Country:US
Mailing Address - Phone:513-857-1815
Mailing Address - Fax:
Practice Address - Street 1:7469 CINNAMON WOODS DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-1041
Practice Address - Country:US
Practice Address - Phone:859-322-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0387182Medicaid