Provider Demographics
NPI:1477743862
Name:HEIDER, JAMES PAUL (EDS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:PAUL
Last Name:HEIDER
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1540 CAPITOL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2235
Mailing Address - Country:US
Mailing Address - Phone:920-491-9800
Mailing Address - Fax:920-491-9800
Practice Address - Street 1:1540 CAPITOL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2235
Practice Address - Country:US
Practice Address - Phone:920-491-9800
Practice Address - Fax:920-491-9800
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI970057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39081000Medicaid