Provider Demographics
NPI:1376584847
Name:PENDLETON, HEIDI J (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:J
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:J
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0301
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-268-9780
Practice Address - Street 1:325 BUTTS AVENUE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1412
Practice Address - Country:US
Practice Address - Phone:608-372-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40939200Medicaid
WI029042001Medicare ID - Type Unspecified