Provider Demographics
NPI:1083751416
Name:HEINEKE, WILLIAM FREDRICK (ED D)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FREDRICK
Last Name:HEINEKE
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3246
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3246
Mailing Address - Country:US
Mailing Address - Phone:307-689-3522
Mailing Address - Fax:
Practice Address - Street 1:311 S GILLETTE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3709
Practice Address - Country:US
Practice Address - Phone:307-299-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPSYCHOLOGIST 423101YP2500X
WYLMFT 53101YP2500X
WYLPC 346101YP2500X
WYLPC346103TC0700X
WYLMFT53103TC0700X
WYLP423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY220179800Medicaid
WY131573100Medicaid