Provider Demographics
NPI:1740613272
Name:HEINLEIN, MICHAEL D (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:HEINLEIN
Suffix:
Gender:M
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:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93515-0273
Mailing Address - Country:US
Mailing Address - Phone:760-920-9888
Mailing Address - Fax:
Practice Address - Street 1:620A KEOUGH ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2534
Practice Address - Country:US
Practice Address - Phone:760-920-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW825971041C0700X, 1041C0700X
CA32457104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker