Provider Demographics
NPI:1205392198
Name:HEIDORF, STEPHEN R
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:HEIDORF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22001 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4819
Mailing Address - Country:US
Mailing Address - Phone:216-320-8438
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HTS
Practice Address - State:OH
Practice Address - Zip Code:44118
Practice Address - Country:US
Practice Address - Phone:216-320-8438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X
OHS.1900863-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)