Provider Demographics
NPI:1972134492
Name:HEINEMANN, TAYLOR (SUDCC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:HEINEMANN
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 ANTARES CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-7743
Mailing Address - Country:US
Mailing Address - Phone:310-448-3959
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:209-383-2203
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1376100120101YA0400X
CA13650101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty