MEDICARE: LAURA M HEIDEMAN LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1024807	MA

General Provider Information

NPI Number	:	1366507964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA M HEIDEMAN LICSW

Provider Business Mailing Address
First Line	:	31 AMORY AVE
Second Line	:
City	:	MAYNARD
State	:	MA
Zip	:	01754-1157
Country	:	US
Telephone Number	:	617-354-8655
Fax Number	:

Provider Business Practice Location Address
First Line	:	2464 MASSACHUSETTS AVE
Second Line	:	312
City	:	CAMBRIDGE
State	:	MA
Zip	:	02140-1646
Country	:	US
Telephone Number	:	617-354-8655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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