Provider Demographics
NPI:1356735500
Name:HEIDORN, ERICK (MFTI)
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:HEIDORN
Suffix:
Gender:M
Credentials:MFTI
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 4926
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-4926
Mailing Address - Country:US
Mailing Address - Phone:707-322-9257
Mailing Address - Fax:
Practice Address - Street 1:3322 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1708
Practice Address - Country:US
Practice Address - Phone:707-322-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85647106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist