Provider Demographics
NPI:1447294947
Name:KILGORE, HEATH (PSYD)
Entity type:Individual
Prefix:DR
First Name:HEATH
Middle Name:
Last Name:KILGORE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-257-9339
Mailing Address - Fax:602-265-8574
Practice Address - Street 1:1424 S 7TH AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-5902
Practice Address - Country:US
Practice Address - Phone:602-258-3600
Practice Address - Fax:602-256-0514
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3781103TA0400X, 103TB0200X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100234Medicaid
Z111466Medicare PIN