Provider Demographics
NPI:1043727498
Name:HEIDELOFF, GRETCHEN (LISW)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:HEIDELOFF
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3298
Mailing Address - Country:US
Mailing Address - Phone:614-384-7798
Mailing Address - Fax:614-384-7703
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:614-935-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
OHI.21031091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1043727498Medicaid