Provider Demographics
NPI:1790243194
Name:VAN DIEST, HEATHER (MPH, LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:VAN DIEST
Suffix:
Gender:F
Credentials:MPH, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 MUELLER BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3051
Mailing Address - Country:US
Mailing Address - Phone:617-216-6574
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX560781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty