Provider Demographics
NPI:1447773965
Name:LAUDERBACK, HEATHER (LISW-S)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LAUDERBACK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 TALL PINE DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035
Mailing Address - Country:US
Mailing Address - Phone:614-600-0469
Mailing Address - Fax:
Practice Address - Street 1:6515 PULLMAN DR STE 2200
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-7381
Practice Address - Country:US
Practice Address - Phone:614-688-7076
Practice Address - Fax:614-688-7155
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00083261041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL WORK
OH$$$$$$$$$OtherSOCIAL WORK