Provider Demographics
NPI:1477685568
Name:HEILBRUN, GWEN K (LISW)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:K
Last Name:HEILBRUN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11223 CORNELL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:513-766-3304
Mailing Address - Fax:513-469-5286
Practice Address - Street 1:11223 CORNELL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242
Practice Address - Country:US
Practice Address - Phone:513-766-3304
Practice Address - Fax:513-469-5286
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI3259104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
19401Medicare ID - Type Unspecified