Healthcare Provider Details

I. General information

NPI: 1780069559
Provider Name (Legal Business Name): HEATHER RAE NEMETHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER RAE KORB

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 E MAIN ST
BENTON HARBOR MI
49022-3036
US

IV. Provider business mailing address

1022 E MAIN ST
BENTON HARBOR MI
49022-3036
US

V. Phone/Fax

Practice location:
  • Phone: 269-926-0015
  • Fax: 269-926-0123
Mailing address:
  • Phone: 269-926-0015
  • Fax: 269-926-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: