Provider Demographics
NPI:1487863874
Name:HEIDERSCHEIT, ANNIE LYNNE (PHD, MT-BC, FAMI)
Entity Type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:LYNNE
Last Name:HEIDERSCHEIT
Suffix:
Gender:F
Credentials:PHD, MT-BC, FAMI
Other - Prefix:DR
Other - First Name:ANNETTE
Other - Middle Name:LYNNE
Other - Last Name:HEIDERSCHEIT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LMFT
Mailing Address - Street 1:1660 HIGHWAY 100 S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1529
Mailing Address - Country:US
Mailing Address - Phone:612-741-1182
Mailing Address - Fax:
Practice Address - Street 1:1660 HIGHWAY 100 S
Practice Address - Street 2:SUITE 250
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1529
Practice Address - Country:US
Practice Address - Phone:612-741-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X
MN2301106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist