Provider Demographics
NPI:1124370358
Name:HEIDENREICH, ELIZABETH ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:HEIDENREICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:13603 80TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8961
Practice Address - Country:US
Practice Address - Phone:763-274-3120
Practice Address - Fax:763-274-3121
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05232103TC0700X
DCPSY1000836103TC0700X
MNGL0077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical