Healthcare Provider Details

I. General information

NPI: 1396876504
Provider Name (Legal Business Name): KIM C HEISKELL OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E. WOOD
CLEARWATER KS
67026-9757
US

IV. Provider business mailing address

13303 SW 210TH
DOUGLASS KS
67039
US

V. Phone/Fax

Practice location:
  • Phone: 620-584-4542
  • Fax:
Mailing address:
  • Phone: 316-747-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17-01565
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: