Basic Information
| Provider Information | |||||||||
| NPI: | 1770025942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIDEMAN | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 TUCKER RD | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970319591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413992966 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2507 CHRISTIE DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036353416 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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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 | 101Y00000X | 2113030 | OR | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.