Provider Demographics
NPI:1083032635
Name:PEDERSEN, HEATHER (PHD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CLOVIS AVENUE #104
Mailing Address - Street 2:264 CLOVIS AVENUE #104
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612
Mailing Address - Country:US
Mailing Address - Phone:559-777-9061
Mailing Address - Fax:
Practice Address - Street 1:264 CLOVIS AVE # 104
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1115
Practice Address - Country:US
Practice Address - Phone:559-777-9061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31209103TA0700X, 103TB0200X, 103TC0700X, 103TM1800X, 103TR0400X, 103G00000X
MNLP5728103TC0700X
103TC1900X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth