Provider Demographics
NPI:1023547379
Name:HEISE, MOLLY MORAVEC
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MORAVEC
Last Name:HEISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14365 GENEVA AVE N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8331
Mailing Address - Country:US
Mailing Address - Phone:651-246-9190
Mailing Address - Fax:
Practice Address - Street 1:555 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1175
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5279
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304814101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)