Provider Demographics
NPI:1790849610
Name:HEARTLAND CLINIC
Entity Type:Organization
Organization Name:HEARTLAND CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SUSANNAH
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:DEVAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LSW
Authorized Official - Phone:765-446-9898
Mailing Address - Street 1:2201 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3047
Mailing Address - Country:US
Mailing Address - Phone:765-446-9898
Mailing Address - Fax:
Practice Address - Street 1:2201 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3047
Practice Address - Country:US
Practice Address - Phone:765-446-9898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005046A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty