Provider Demographics
NPI:1639161532
Name:MUSGRAVE, HEIDI L (PHD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:MUSGRAVE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:L
Other - Last Name:PICKELMAN HEDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2250 LAKE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5352
Mailing Address - Country:US
Mailing Address - Phone:260-409-2099
Mailing Address - Fax:
Practice Address - Street 1:2250 LAKE AVE STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5352
Practice Address - Country:US
Practice Address - Phone:260-409-2099
Practice Address - Fax:260-436-2135
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041626A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200303330Medicaid
IN221290AMedicare PIN