Provider Demographics
NPI:1720560675
Name:ANDERSON, HEIDI (LCSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 JACK NICKLAUS WAY
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2225
Mailing Address - Country:US
Mailing Address - Phone:505-412-5292
Mailing Address - Fax:
Practice Address - Street 1:160 DUGGAN AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-4812
Practice Address - Country:US
Practice Address - Phone:505-412-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW169741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical