Provider Demographics
NPI:1952735201
Name:HEINZ, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:HEINZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:MAROA
Mailing Address - State:IL
Mailing Address - Zip Code:61756-9235
Mailing Address - Country:US
Mailing Address - Phone:217-620-6007
Mailing Address - Fax:
Practice Address - Street 1:218 N BIRCH ST
Practice Address - Street 2:
Practice Address - City:MAROA
Practice Address - State:IL
Practice Address - Zip Code:61756-9235
Practice Address - Country:US
Practice Address - Phone:217-620-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist