Healthcare Provider Details

I. General information

NPI: 1245616465
Provider Name (Legal Business Name): NICHOLAS HEUERMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 W RICHWOODS BLVD
PEORIA IL
61604-7112
US

IV. Provider business mailing address

2610 W RICHWOODS BLVD
PEORIA IL
61604-7112
US

V. Phone/Fax

Practice location:
  • Phone: 309-323-6643
  • Fax:
Mailing address:
  • Phone: 309-323-6643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149,017817
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: