Basic Information
| Provider Information | |||||||||
| NPI: | 1487783874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIDERICH | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8919 LARIAT LOOP | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801079317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036463192 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1920 E 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033212482 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.