Provider Demographics
NPI:1285213124
Name:HEIDTMAN, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HEIDTMAN
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 1:103 W GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1115
Mailing Address - Country:US
Mailing Address - Phone:906-362-8544
Mailing Address - Fax:
Practice Address - Street 1:103 W GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-1115
Practice Address - Country:US
Practice Address - Phone:906-362-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8764-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty