Provider Demographics
NPI:1003194903
Name:HEIDEMANN, MELISSA MARIE (LISW-S)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:HEIDEMANN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 THORNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-6151
Mailing Address - Country:US
Mailing Address - Phone:440-423-5933
Mailing Address - Fax:
Practice Address - Street 1:1848 THORNWOOD LN
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-6151
Practice Address - Country:US
Practice Address - Phone:440-423-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHL.1100197-SUPV104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid