Basic Information
| Provider Information | |||||||||
| NPI: | 1033374038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIDEMAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PHD.L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1309 | ||||||||
| Address2: | 8170 33RD AVE S MAIL STOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515522600 | ||||||||
| FaxNumber: | 6515522614 | ||||||||
| Practice Location | |||||||||
| Address1: | 5625 CENEX DR | ||||||||
| Address2: | MAIL STOP 33100A | ||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550771724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515522600 | ||||||||
| FaxNumber: | 6515522614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2008 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP5154 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.