Healthcare Provider Details

I. General information

NPI: 1982774501
Provider Name (Legal Business Name): ELIZABETH HEIDLER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BROADWAY ST
KING CITY CA
93930-3130
US

IV. Provider business mailing address

PO BOX 1226
KING CITY CA
93930-1226
US

V. Phone/Fax

Practice location:
  • Phone: 831-596-8194
  • Fax: 831-385-8100
Mailing address:
  • Phone: 831-596-8194
  • Fax: 831-385-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 15290
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 15290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: