Provider Demographics
NPI:1336488535
Name:HALTOM, HEIDI ANN (LPT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ANN
Last Name:HALTOM
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 OLD DAIRY DR
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5034
Mailing Address - Country:US
Mailing Address - Phone:916-757-2352
Mailing Address - Fax:
Practice Address - Street 1:935 SPRING ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4543
Practice Address - Country:US
Practice Address - Phone:530-621-6213
Practice Address - Fax:530-622-2385
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health