Provider Demographics
NPI:1811555063
Name:WODIS, HEATHER (PH D)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:WODIS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1161 LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5649
Mailing Address - Country:US
Mailing Address - Phone:847-498-5437
Mailing Address - Fax:
Practice Address - Street 1:1161 LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5649
Practice Address - Country:US
Practice Address - Phone:847-498-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-19-86121106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician