Provider Demographics
NPI:1215044359
Name:HEISE, AMY MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:HEISE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:HUMPHRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2812
Mailing Address - Country:US
Mailing Address - Phone:520-991-9198
Mailing Address - Fax:
Practice Address - Street 1:300 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2812
Practice Address - Country:US
Practice Address - Phone:520-417-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-3964235Z00000X
AZ5810235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist