Provider Demographics
NPI:1043370372
Name:HEYNEMAN, NICHOLAS E (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:HEYNEMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 YALE ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3436
Mailing Address - Country:US
Mailing Address - Phone:208-234-7740
Mailing Address - Fax:208-392-1541
Practice Address - Street 1:850 E CENTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5737
Practice Address - Country:US
Practice Address - Phone:208-234-7740
Practice Address - Fax:208-392-1541
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017340OtherREGENCE BLUE SHIELD
IDN-2340OtherBLUE CROSS
ID1681028Medicare ID - Type Unspecified