Provider Demographics
NPI:1629126867
Name:HEIMBUCH, CLOTILDA BROKAW (MS)
Entity Type:Individual
Prefix:MS
First Name:CLOTILDA
Middle Name:BROKAW
Last Name:HEIMBUCH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:CHLOE
Other - Middle Name:BROKAW
Other - Last Name:HEIMBUCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:300 MOUNT LEBANON BLVD
Mailing Address - Street 2:2214
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15234-1512
Mailing Address - Country:US
Mailing Address - Phone:412-563-0650
Mailing Address - Fax:
Practice Address - Street 1:300 MOUNT LEBANON BLVD
Practice Address - Street 2:2214
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15234-1512
Practice Address - Country:US
Practice Address - Phone:412-563-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000380106H00000X
CAMF23577106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist