Provider Demographics
NPI:1770095192
Name:FORTWANGLER-IRR, HEIDI MARIE
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:FORTWANGLER-IRR
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 1:949 BEAVER GRADE RD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2717
Mailing Address - Country:US
Mailing Address - Phone:412-874-5807
Mailing Address - Fax:724-457-2824
Practice Address - Street 1:949 BEAVER GRADE RD
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108-2717
Practice Address - Country:US
Practice Address - Phone:412-874-5807
Practice Address - Fax:724-457-2824
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009942101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional