Provider Demographics
NPI:1396773065
Name:HEISE, RICHARD A (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:HEISE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W PORT PLZ STE 600
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3015
Mailing Address - Country:US
Mailing Address - Phone:314-399-9707
Mailing Address - Fax:314-474-0119
Practice Address - Street 1:111 W PORT PLZ STE 600
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3015
Practice Address - Country:US
Practice Address - Phone:314-399-9707
Practice Address - Fax:314-474-0119
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497724906Medicaid