Healthcare Provider Details

I. General information

NPI: 1295443620
Provider Name (Legal Business Name): HEATHER KNICKERBOCKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DANFORTH DR
EASTON PA
18045-7820
US

IV. Provider business mailing address

6 DANFORTH DR
EASTON PA
18045-7820
US

V. Phone/Fax

Practice location:
  • Phone: 610-555-5550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: