Provider Demographics
NPI:1518312792
Name:HEATWOLE, SETH (MS LMFT)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:HEATWOLE
Suffix:
Gender:M
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W BOESCH DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-9391
Mailing Address - Country:US
Mailing Address - Phone:209-968-0653
Mailing Address - Fax:
Practice Address - Street 1:625 W BOESCH DR
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-9391
Practice Address - Country:US
Practice Address - Phone:209-968-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52849106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist