Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 2012035820 | MO |
NPI | 1003155243 |
---|---|
Provider Name | Ms. Kelly M Heironimus |
First Address | Sikeston, MO 63801-5736 |
Second Address | Sikeston, MO 63801-5736 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2013 |
Last Update Date | 07/02/2013 |