=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205100054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK F HEILAND, PHD, LICENSED PSYCHOLOGIST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2012
-----------------------------------------------------
Last Update Date | 02/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4542 W PINE BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-2186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-609-5532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4542 WEST PINE BLVD
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-609-5532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARK F HEILAND
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 314-609-5532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 2009018630
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------