Provider Demographics
NPI:1407449598
Name:DINKLAGE, HEATHER ELIZABETH (EDS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:DINKLAGE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2116
Mailing Address - Country:US
Mailing Address - Phone:419-283-5790
Mailing Address - Fax:
Practice Address - Street 1:307 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-1813
Practice Address - Country:US
Practice Address - Phone:440-434-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21204854103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool