Basic Information
| Provider Information | |||||||||
| NPI: | 1003194903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIDEMANN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
| FaxNumber: | 4402052417 | ||||||||
| Practice Location | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
| FaxNumber: | 4402052417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2011 | ||||||||
| LastUpdateDate: | 07/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1100197 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2069738 | 05 | OH | MEDICAID |