Provider Demographics
NPI:1164494258
Name:BLANK, HEIDI JOYCE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:JOYCE
Last Name:BLANK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7535 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3643
Mailing Address - Country:US
Mailing Address - Phone:520-298-0651
Mailing Address - Fax:
Practice Address - Street 1:5380 E KACHINA ST
Practice Address - Street 2:355TH MDOS/SGOH
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707-4923
Practice Address - Country:US
Practice Address - Phone:520-228-4926
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-118981041C0700X
NYR035089-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical