Provider Demographics
NPI:1831565472
Name:COSIMO, HEATHER (MA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:COSIMO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 SMALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7771
Mailing Address - Country:US
Mailing Address - Phone:850-530-3807
Mailing Address - Fax:
Practice Address - Street 1:1913 HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-1017
Practice Address - Country:US
Practice Address - Phone:850-692-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 13768101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health