Provider Demographics
NPI:1255764627
Name:HEIDENBERG, BRADLEY THOMAS (LMFT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:THOMAS
Last Name:HEIDENBERG
Suffix:
Gender:M
Credentials:LMFT
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 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0087
Mailing Address - Country:US
Mailing Address - Phone:209-381-6800
Mailing Address - Fax:
Practice Address - Street 1:1275 B ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA98495106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional