Provider Demographics
NPI:1659579670
Name:MAGEE, HEATHER E (PHD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:MAGEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 S FLORIDA AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2169
Mailing Address - Country:US
Mailing Address - Phone:863-709-8110
Mailing Address - Fax:863-709-8118
Practice Address - Street 1:4404 S FLORIDA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2169
Practice Address - Country:US
Practice Address - Phone:863-709-8110
Practice Address - Fax:863-709-8118
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 103TB0200X
NE691103T00000X
FLPY8345103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE8172Medicaid