Provider Demographics
NPI:1780650796
Name:HEILAND, MARK F (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:HEILAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 WEST PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-609-5532
Mailing Address - Fax:
Practice Address - Street 1:4542 WEST PINE BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-609-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009018630103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral