Healthcare Provider Details

I. General information

NPI: 1659622462
Provider Name (Legal Business Name): DAVID J HEITMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E ELM ST
REPUBLIC MO
65738-1552
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5511
  • Fax: 417-761-5512
Mailing address:
  • Phone: 417-761-5000
  • Fax: 417-761-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-R-22
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2023000446
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: