Healthcare Provider Details

I. General information

NPI: 1437773595
Provider Name (Legal Business Name): EMILY HEIBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 PACIFIC AVE
FOREST GROVE OR
97116-2226
US

IV. Provider business mailing address

6805 SW NYBERG ST APT E304
TUALATIN OR
97062-8333
US

V. Phone/Fax

Practice location:
  • Phone: 503-359-0449
  • Fax:
Mailing address:
  • Phone: 541-992-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1009851
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: