Basic Information
| Provider Information | |||||||||
| NPI: | 1598708273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINE | ||||||||
| FirstName: | JONI | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S BROADWAY | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S BROADWAY | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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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 | 1041C0700X | 3453 | ND | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 225800000X | 29912 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist |
ID Information
| ID | Type | State | Issuer | Description | 021926 | 01 | BCBS OF ND PIN | OTHER | N21926 | 01 | RR MEDICARE PIN | OTHER |