Basic Information
| Provider Information | |||||||||
| NPI: | 1700938081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIMLICH | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.A., L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1457 ARDEN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | ARDEN HILLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516364176 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7590 LYRIC LN NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554323251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632363800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 103T00000X | LP 3651 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 4181781 | 01 | MN | MN TAX ID # | OTHER | 45Q48HE & 45Q51HE | 01 | MN | BCBS OF MN | OTHER |