Provider Demographics
NPI:1255389706
Name:HEIDENREICH, DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HEIDENREICH
Suffix:
Gender:M
Credentials:LCSW
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 4323
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-0323
Mailing Address - Country:US
Mailing Address - Phone:812-231-8323
Mailing Address - Fax:812-231-8400
Practice Address - Street 1:4755 KINGSWAY DR
Practice Address - Street 2:SUITE 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1549
Practice Address - Country:US
Practice Address - Phone:317-253-3791
Practice Address - Fax:317-253-6150
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340000171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN608950JMedicare ID - Type Unspecified