Basic Information
| Provider Information | |||||||||
| NPI: | 1023547379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEISE | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | MORAVEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14365 GENEVA AVE N | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550388331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512469190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | FOREST LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550251175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2017 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 304814 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.