Healthcare Provider Details

I. General information

NPI: 1457260721
Provider Name (Legal Business Name): LIOBA V. HEINEMAN MS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRINDA V BURKHARDT

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 11TH AVE SE
FOREST LAKE MN
55025-1823
US

IV. Provider business mailing address

246 11TH AVE SE
FOREST LAKE MN
55025-1823
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-0771
  • Fax:
Mailing address:
  • Phone: 651-464-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1052432
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: