Provider Demographics
NPI:1528009958
Name:GEPHART, HEIDI JO (EDM)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:GEPHART
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2299
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-0699
Mailing Address - Country:US
Mailing Address - Phone:509-765-4530
Mailing Address - Fax:509-766-0795
Practice Address - Street 1:832 SHARON AVE E STE D
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2442
Practice Address - Country:US
Practice Address - Phone:509-765-9239
Practice Address - Fax:509-765-1582
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health