Provider Demographics
NPI:1801955315
Name:HECKENLAIBLE-GOTTO, MYRA JEAN (LP)
Entity type:Individual
Prefix:DR
First Name:MYRA
Middle Name:JEAN
Last Name:HECKENLAIBLE-GOTTO
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S MINNESOTA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4871
Mailing Address - Country:US
Mailing Address - Phone:605-334-7713
Mailing Address - Fax:
Practice Address - Street 1:1450 HIGHWAY 60 71 N
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-2025
Practice Address - Country:US
Practice Address - Phone:605-334-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4507103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling