Provider Demographics
NPI:1013187541
Name:HERON RIDGE ASSOCIATES, PLC
Entity Type:Organization
Organization Name:HERON RIDGE ASSOCIATES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SECRETARY, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-605-4986
Mailing Address - Street 1:3694 CLARKSTON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5213
Mailing Address - Country:US
Mailing Address - Phone:248-693-8880
Mailing Address - Fax:248-391-7478
Practice Address - Street 1:31000 TELEGRAPH RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4360
Practice Address - Country:US
Practice Address - Phone:248-594-4991
Practice Address - Fax:248-391-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI631056261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI463240OtherVALUE OPTIONS
MI750910409OtherBLUE CROSS BLUE SHIELD
MI463240OtherVALUE OPTIONS