Provider Demographics
NPI:1356985162
Name:HEITKAMP, KIRSTEN M (LCSW)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:HEITKAMP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:M
Other - Last Name:EBERLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:
Practice Address - Street 1:325 S OAK ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-2244
Practice Address - Country:US
Practice Address - Phone:765-584-1735
Practice Address - Fax:765-584-5407
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008640A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical