Healthcare Provider Details

I. General information

NPI: 1861194227
Provider Name (Legal Business Name): HEIDI MOLLENKOPF MSW, LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W CHURCH ST
ELIZABETH CITY NC
27909-4510
US

IV. Provider business mailing address

904 MCPHERSON ST
ELIZABETH CITY NC
27909-4635
US

V. Phone/Fax

Practice location:
  • Phone: 252-331-0322
  • Fax:
Mailing address:
  • Phone: 252-619-2749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018054
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: