Provider Demographics
NPI:1497938161
Name:LIDER, HEATHER LOUISE (BS, LAC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LOUISE
Last Name:LIDER
Suffix:
Gender:F
Credentials:BS, LAC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LOUISE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 18
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1015 S BROADWAY
Practice Address - Street 2:SUITE 18
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-857-8500
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND030607OtherBLUE CROSS BLUE SHIELD
ND54517Medicaid