Provider Demographics
NPI:1447940390
Name:HEATH, ANTONIA
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:HEATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4799
Mailing Address - Street 2:
Mailing Address - City:ARIZONA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85123-2758
Mailing Address - Country:US
Mailing Address - Phone:480-682-7682
Mailing Address - Fax:
Practice Address - Street 1:4501 N CAMINO DEL OBISPO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6605
Practice Address - Country:US
Practice Address - Phone:855-462-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD11119384106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician