Provider Demographics
NPI:1346940970
Name:EDSALL, HEIDI LIESE LIESE (AMFT)
Entity Type:Individual
Prefix:
First Name:HEIDI LIESE
Middle Name:LIESE
Last Name:EDSALL
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 MALTMAN AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2757
Mailing Address - Country:US
Mailing Address - Phone:323-702-3549
Mailing Address - Fax:
Practice Address - Street 1:1555 W SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-3333
Practice Address - Country:US
Practice Address - Phone:747-215-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT137924106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist