Healthcare Provider Details

I. General information

NPI: 1376173187
Provider Name (Legal Business Name): HEIDI CARMODY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI PATTEN

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 12TH AVE
LONGVIEW WA
98632-2403
US

IV. Provider business mailing address

7729 NE QUARRY RD
LA CENTER WA
98629-5221
US

V. Phone/Fax

Practice location:
  • Phone: 360-998-2349
  • Fax: 360-998-2887
Mailing address:
  • Phone: 360-431-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSA61032041
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSA61032041
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSA61032041
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: