Healthcare Provider Details

I. General information

NPI: 1518758929
Provider Name (Legal Business Name): HEIDI HUFFMAN LPC INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E SHORE DR
EAGLE ID
83616-6908
US

IV. Provider business mailing address

4622 W MARICOPA DR
EAGLE ID
83616-4480
US

V. Phone/Fax

Practice location:
  • Phone: 949-444-3809
  • Fax:
Mailing address:
  • Phone: 949-444-3809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberINTERN
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: