Provider Demographics
NPI:1841379823
Name:MUNTJANOFF, HEIDI MARIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:MARIA
Last Name:MUNTJANOFF
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 1:623 N 1ST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3155
Mailing Address - Country:US
Mailing Address - Phone:815-756-2648
Mailing Address - Fax:
Practice Address - Street 1:920 W PRAIRIE DR
Practice Address - Street 2:SUITE F
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3123
Practice Address - Country:US
Practice Address - Phone:815-899-0501
Practice Address - Fax:815-899-2098
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ37182Medicare UPIN