Basic Information
| Provider Information | |||||||||
| NPI: | 1588057004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIDECKE | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRC, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUX | ||||||||
| OtherFirstName: | CARMEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4347 SUNNYVIEW RD. NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2015 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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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 | 101YP2500X | C4060 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.