Provider Demographics
NPI:1376173187
Name:CARMODY, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:CARMODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:PATTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7729 NE QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-5221
Mailing Address - Country:US
Mailing Address - Phone:360-431-1684
Mailing Address - Fax:
Practice Address - Street 1:831 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2403
Practice Address - Country:US
Practice Address - Phone:360-998-2349
Practice Address - Fax:360-998-2887
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA61032041101YM0800X, 104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2205741Medicaid