Provider Demographics
NPI:1073186672
Name:HEIST, SUSANNAH PAIGE
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:PAIGE
Last Name:HEIST
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 1:5280 N SORRENTO DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-2353
Mailing Address - Country:US
Mailing Address - Phone:208-908-2450
Mailing Address - Fax:
Practice Address - Street 1:3622 W ROSE HILL ST APT 203
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5180
Practice Address - Country:US
Practice Address - Phone:208-908-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-08-03
Deactivation Date:2021-07-21
Deactivation Code:
Reactivation Date:2021-08-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician