Healthcare Provider Details

I. General information

NPI: 1679584783
Provider Name (Legal Business Name): WALTER HEIZENROTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

IV. Provider business mailing address

6 WOODVIEW RD
MALVERN PA
19355-2119
US

V. Phone/Fax

Practice location:
  • Phone: 610-384-7711
  • Fax:
Mailing address:
  • Phone: 610-948-0981
  • Fax: 610-948-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS005637L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: