Provider Demographics
NPI:1891386421
Name:HEIDEL, BETHANY ANNE (TLLP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
Last Name:HEIDEL
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1613
Mailing Address - Country:US
Mailing Address - Phone:470-309-3260
Mailing Address - Fax:
Practice Address - Street 1:949 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1613
Practice Address - Country:US
Practice Address - Phone:470-309-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009272103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling