Provider Demographics
NPI:1437773595
Name:HEIBERG, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HEIBERG
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 1:6805 SW NYBERG ST APT E304
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8333
Mailing Address - Country:US
Mailing Address - Phone:541-992-2521
Mailing Address - Fax:
Practice Address - Street 1:3900 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2226
Practice Address - Country:US
Practice Address - Phone:503-359-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1009851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered