Provider Demographics
NPI:1942211677
Name:HEDDLESTEN, DEBRA MARIE (MED, LADC, CM-D)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:MARIE
Last Name:HEDDLESTEN
Suffix:
Gender:F
Credentials:MED, LADC, CM-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:ALBERT
Mailing Address - State:OK
Mailing Address - Zip Code:73001-0092
Mailing Address - Country:US
Mailing Address - Phone:580-330-2247
Mailing Address - Fax:
Practice Address - Street 1:120 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3643
Practice Address - Country:US
Practice Address - Phone:580-623-2548
Practice Address - Fax:580-623-2668
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK566101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3DMH58OtherICIS ID