Provider Demographics
NPI:1114770419
Name:HEIDEMANN, MARIE CHRISTINE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CHRISTINE
Last Name:HEIDEMANN
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 1:8105 DERBY RUN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-8782
Mailing Address - Country:US
Mailing Address - Phone:480-452-6189
Mailing Address - Fax:
Practice Address - Street 1:7167 COLLEYVILLE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8002
Practice Address - Country:US
Practice Address - Phone:682-593-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional