Provider Demographics
NPI:1083188320
Name:BERTHELSEN, HEIDI MICHELLE
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MICHELLE
Last Name:BERTHELSEN
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 1:14107 AMES AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-5005
Mailing Address - Country:US
Mailing Address - Phone:402-968-9331
Mailing Address - Fax:
Practice Address - Street 1:4102 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1851
Practice Address - Country:US
Practice Address - Phone:402-444-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001950235Z00000X
NE1390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist