Healthcare Provider Details

I. General information

NPI: 1720722465
Provider Name (Legal Business Name): HEIDI SMITH LPC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 MAIN ST STE 3
WANAMINGO MN
55983-3848
US

IV. Provider business mailing address

1340 SLALOM BALL LN SW
PINE ISLAND MN
55963-5001
US

V. Phone/Fax

Practice location:
  • Phone: 507-626-2410
  • Fax:
Mailing address:
  • Phone: 507-244-0190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number02176
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: