Provider Demographics
NPI:1891825576
Name:GWEN HEATON, MD
Entity Type:Organization
Organization Name:GWEN HEATON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-265-4151
Mailing Address - Street 1:606 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4708
Mailing Address - Country:US
Mailing Address - Phone:812-265-4151
Mailing Address - Fax:812-265-5028
Practice Address - Street 1:606 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4708
Practice Address - Country:US
Practice Address - Phone:812-265-4151
Practice Address - Fax:812-265-5028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004330A104100000X
IN33002012A104100000X
IN34001704A1041C0700X
IN34000171A1041C0700X
IN35000998A106H00000X
IN35000907A106H00000X
IN010357822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty