Healthcare Provider Details

I. General information

NPI: 1902389190
Provider Name (Legal Business Name): JOSEPH DAVID HEILMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NICOLE MARIE SEVERSON

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S EL CAMINO REAL STE 200
SAN MATEO CA
94403-2382
US

IV. Provider business mailing address

53 EAST HILLSDALE BLVRD
SAN MATEO CA
94404
US

V. Phone/Fax

Practice location:
  • Phone: 650-578-8691
  • Fax:
Mailing address:
  • Phone: 510-681-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: