Healthcare Provider Details

I. General information

NPI: 1508173360
Provider Name (Legal Business Name): ANNELISE P HEITMAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E 10TH AVE SUITE 330
EUGENE OR
97401-3317
US

IV. Provider business mailing address

1672 WILSON CT
EUGENE OR
97402-3361
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-2004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0723
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: