Provider Demographics
NPI:1457483919
Name:HEINE, MARK AUSTIN (LCSW, PPSC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AUSTIN
Last Name:HEINE
Suffix:
Gender:M
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5024
Mailing Address - Country:US
Mailing Address - Phone:530-273-4431
Mailing Address - Fax:530-274-1483
Practice Address - Street 1:11645 RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5024
Practice Address - Country:US
Practice Address - Phone:530-273-4431
Practice Address - Fax:530-271-5943
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YS0200X
CA296031041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical