Healthcare Provider Details

I. General information

NPI: 1093447864
Provider Name (Legal Business Name): HEIDI GERGURICH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 10/03/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43082 PUDDING CT
TEMECULA CA
92592-4355
US

IV. Provider business mailing address

43082 PUDDING CT
TEMECULA CA
92592-4355
US

V. Phone/Fax

Practice location:
  • Phone: 951-387-8039
  • Fax:
Mailing address:
  • Phone: 951-387-8039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: