Provider Demographics
NPI:1669544276
Name:WISTE, HEIDI PARK (LICSW)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:PARK
Last Name:WISTE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:HEIDI
Other - Middle Name:PARK
Other - Last Name:WEITZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:2230 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1720
Mailing Address - Country:US
Mailing Address - Phone:651-635-0095
Mailing Address - Fax:651-635-0454
Practice Address - Street 1:2230 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1720
Practice Address - Country:US
Practice Address - Phone:651-635-0095
Practice Address - Fax:651-635-0454
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15091104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker