Provider Demographics
NPI:1073559951
Name:HEINZEN, THOMAS EDWARD
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWARD
Last Name:HEINZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1329
Mailing Address - Country:US
Mailing Address - Phone:973-748-0622
Mailing Address - Fax:
Practice Address - Street 1:476 CHRISTIAN HERALD RD
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2230
Practice Address - Country:US
Practice Address - Phone:845-268-6861
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 012043103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01592781Medicaid