Provider Demographics
NPI:1558687665
Name:ISON, HEIDI A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:A
Last Name:ISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:HEIDI
Other - Middle Name:A
Other - Last Name:PETRACCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2005 PAN AM CIR STE 120
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2529
Mailing Address - Country:US
Mailing Address - Phone:813-602-2312
Mailing Address - Fax:813-302-1173
Practice Address - Street 1:2005 PAN AM CIR STE 120
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2529
Practice Address - Country:US
Practice Address - Phone:813-602-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL97711041C0700X
FLSW97711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2244600Medicaid
FL2244600Medicaid