Healthcare Provider Details

I. General information

NPI: 1134643174
Provider Name (Legal Business Name): HENRY HEIDELBERGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 CALDWELL ST STE B
CONWAY AR
72034-5319
US

IV. Provider business mailing address

PO BOX 23070
BARLING AR
72923-0070
US

V. Phone/Fax

Practice location:
  • Phone: 501-500-4892
  • Fax:
Mailing address:
  • Phone: 479-452-5040
  • Fax: 479-452-5047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberF1707005
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM2010013
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: