Healthcare Provider Details

I. General information

NPI: 1710963137
Provider Name (Legal Business Name): HEIDI MARIE OVERALL-BLOCK M.A. - L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/17/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E 18TH ST
CHEYENNE WY
82001-4618
US

IV. Provider business mailing address

520 E 18TH ST
CHEYENNE WY
82001-4618
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-1228
  • Fax: 307-433-0991
Mailing address:
  • Phone: 307-638-1228
  • Fax: 307-433-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number50
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: