Provider Demographics
NPI:1891253845
Name:HEIDELMAIER, LISA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:HEIDELMAIER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 OLD HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-1715
Mailing Address - Country:US
Mailing Address - Phone:410-545-3086
Mailing Address - Fax:410-545-7870
Practice Address - Street 1:6101 OLD HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1715
Practice Address - Country:US
Practice Address - Phone:410-545-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03973103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical