Healthcare Provider Details

I. General information

NPI: 1366373672
Provider Name (Legal Business Name): LYDIA MUSIIMENTA HEANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LONG LAKE RD
NEW BRIGHTON MN
55112-6428
US

IV. Provider business mailing address

6708 ZEALAND AVE N
MINNEAPOLIS MN
55428-1934
US

V. Phone/Fax

Practice location:
  • Phone: 612-900-0233
  • Fax:
Mailing address:
  • Phone: 952-465-8607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: