Provider Demographics
NPI:1407617053
Name:HEIDELBERG, LEATRICE
Entity Type:Individual
Prefix:
First Name:LEATRICE
Middle Name:
Last Name:HEIDELBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-7684
Mailing Address - Country:US
Mailing Address - Phone:239-645-8297
Mailing Address - Fax:
Practice Address - Street 1:501 MICHAEL AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-1043
Practice Address - Country:US
Practice Address - Phone:239-645-8297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities