MEDICARE: STACEY HEIDLER

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H346-792-82-942-0	OTHER	FL	DRIVERS LISCENSE

General Provider Information

NPI Number	:	1497010052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY HEIDLER

Provider Business Mailing Address
First Line	:	3505 NE 21ST AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-7334
Country	:	US
Telephone Number	:	239-826-2152
Fax Number	:

Provider Business Practice Location Address
First Line	:	6315 PRESIDENTIAL CT STE 110
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3568
Country	:	US
Telephone Number	:	239-826-2152
Fax Number	:

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

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/24/2024

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Directions to “ STACEY HEIDLER ” Practice Location

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