Healthcare Provider Details

I. General information

NPI: 1639877699
Provider Name (Legal Business Name): AVIVA HEINEMANNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 SCOTTS LEVEL ROAD
BALTIMORE MD
21208
US

IV. Provider business mailing address

6520 PEBBLE BROOKE RD
BALTIMORE MD
21209-3857
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number05391
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: