Provider Demographics
NPI:1558115840
Name:LOM, HEATHER (MSW, APSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LOM
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 N WALDOCH DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8445
Mailing Address - Country:US
Mailing Address - Phone:920-858-7592
Mailing Address - Fax:
Practice Address - Street 1:129 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9386
Practice Address - Country:US
Practice Address - Phone:715-588-3371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1476-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker