Provider Demographics
NPI:1740693118
Name:HEIDELBERG, CAROLYN JEAN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:HEIDELBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 SOUTHFIELD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2710
Mailing Address - Country:US
Mailing Address - Phone:567-288-4325
Mailing Address - Fax:
Practice Address - Street 1:6 ABBEY RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3170
Practice Address - Country:US
Practice Address - Phone:567-288-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2938414Medicaid