Provider Demographics
NPI:1457982332
Name:CORWIN, HEATHER LEA (PHD, LPC, RME, MFA)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LEA
Last Name:CORWIN
Suffix:
Gender:F
Credentials:PHD, LPC, RME, MFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1147
Mailing Address - Country:US
Mailing Address - Phone:818-298-1828
Mailing Address - Fax:
Practice Address - Street 1:BLACKBIRD BEHAVIORAL HEALTH
Practice Address - Street 2:715 LAKE STREET, 4TH FLOOR
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-209-8987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015649101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health