MEDICARE: MS. KAREN HEIDRICK VANWISSE LCSW

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	1041C0700X	Clinical Social Worker	39169	TX

General Provider Information

NPI Number	:	1639487135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN HEIDRICK VANWISSE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 40224
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-0004
Country	:	US
Telephone Number	:	512-569-9901
Fax Number	:

Provider Business Practice Location Address
First Line	:	2502 MANOR RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78722-2007
Country	:	US
Telephone Number	:	512-569-9901
Fax Number	:

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

Provider Enumeration Date	:	09/17/2010
Last Update Date	:	09/17/2010

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