Healthcare Provider Details

I. General information

NPI: 1194563858
Provider Name (Legal Business Name): HEIDI JENNIFER HEDRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

8763 SW 27T LN #101
GAINESVILE FL
32608
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-7981
  • Fax:
Mailing address:
  • Phone: 352-265-7810
  • Fax: 352-627-4889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH23854
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH23854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: