Provider Demographics
NPI:1619795812
Name:HEATH, DETRICH SIMMONS (PRS)
Entity type:Individual
Prefix:
First Name:DETRICH
Middle Name:SIMMONS
Last Name:HEATH
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PHILOSOPHERS TER
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1715
Mailing Address - Country:US
Mailing Address - Phone:443-215-5353
Mailing Address - Fax:833-615-2165
Practice Address - Street 1:126 PHILOSOPHERS TER
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1715
Practice Address - Country:US
Practice Address - Phone:443-215-5353
Practice Address - Fax:833-615-2165
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist