Basic Information
Provider Information | |||||||||
NPI: | 1386880136 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEVINE | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GLEE | ||||||||
OtherFirstName: | HEIDI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 421 ZANG ST | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802281052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039894357 | ||||||||
FaxNumber: | 3039882017 | ||||||||
Practice Location | |||||||||
Address1: | 75 CLAREMONT ST STE C | ||||||||
Address2: |   | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599013500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067585155 | ||||||||
FaxNumber: | 4067585166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2008 | ||||||||
LastUpdateDate: | 06/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-5104 | CO | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | BBH-LCPC-LIC-8085 | MT | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.