Provider Demographics
NPI:1467480764
Name:HEIDRICH, ROBERT KEITH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEITH
Last Name:HEIDRICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 BURNSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2611
Practice Address - Country:US
Practice Address - Phone:284-545-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P16690012Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST