Provider Demographics
NPI:1417105495
Name:MCCLUNE, HEIDI ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ELIZABETH
Last Name:MCCLUNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:ELIZABETH
Other - Last Name:BUNGEROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4907 MORENA BLVD
Mailing Address - Street 2:SUITE 1412
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-3463
Mailing Address - Country:US
Mailing Address - Phone:858-272-6100
Mailing Address - Fax:
Practice Address - Street 1:4907 MORENA BLVD
Practice Address - Street 2:SUITE 1412
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3463
Practice Address - Country:US
Practice Address - Phone:858-272-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist