Healthcare Provider Details

I. General information

NPI: 1861595738
Provider Name (Legal Business Name): GERALD HENRY HEISLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 OLD 63 S 101
COLUMBIA MO
65201-6092
US

IV. Provider business mailing address

3108 S OLD RIDGE RD
COLUMBIA MO
65203-9547
US

V. Phone/Fax

Practice location:
  • Phone: 573-823-0710
  • Fax:
Mailing address:
  • Phone: 573-445-8545
  • Fax: 573-884-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberMISSOURI 105
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: