Provider Demographics
NPI:1053023531
Name:HEISE, KATHRYN LEANDRA I (RBT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEANDRA
Last Name:HEISE
Suffix:I
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ADRIS PL
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1997
Mailing Address - Country:US
Mailing Address - Phone:334-618-3302
Mailing Address - Fax:
Practice Address - Street 1:112 ADRIS PL
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1997
Practice Address - Country:US
Practice Address - Phone:334-618-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO21-192158106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO21-192158Other21-192158