Healthcare Provider Details

I. General information

NPI: 1134699028
Provider Name (Legal Business Name): JUSTIN ANTHONY HEUPEL MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 KENT ST STE 2
IRON MOUNTAIN MI
49801-1569
US

IV. Provider business mailing address

97 S 4TH ST STE C
ISHPEMING MI
49849-2168
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-2561
  • Fax: 906-774-2597
Mailing address:
  • Phone: 906-228-9699
  • Fax: 888-977-2109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301017696
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: