=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962003780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN MARIE HEUER LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2020
-----------------------------------------------------
Last Update Date | 11/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51539 VAN DYKE AVE
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48316-4447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-461-2111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23614 MARLBOROUGH DR
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48036-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801104769
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------