Provider Demographics
NPI:1225047491
Name:HEINEMANN, MARVA A (LPC, LMFT, RN)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:A
Last Name:HEINEMANN
Suffix:
Gender:F
Credentials:LPC, LMFT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 170
Mailing Address - Street 2:P. O. BOX 615
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-9110
Mailing Address - Country:US
Mailing Address - Phone:580-286-5050
Mailing Address - Fax:580-286-2273
Practice Address - Street 1:RR 5 BOX 170
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-9110
Practice Address - Country:US
Practice Address - Phone:580-286-5050
Practice Address - Fax:580-286-2273
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist