Healthcare Provider Details

I. General information

NPI: 1598175440
Provider Name (Legal Business Name): DR. HEIDI MARIE MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI MARIE PEDERSON PSYD

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E 38TH ST
ERIE PA
16504-1559
US

IV. Provider business mailing address

135 E 38TH ST BLDG 8
ERIE PA
16504-1559
US

V. Phone/Fax

Practice location:
  • Phone: 814-488-3732
  • Fax:
Mailing address:
  • Phone: 814-488-3732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006146
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: