MEDICARE: HEIDI A OLIVER PSYD

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	103TC0700X	Clinical Psychologist	LP-2657	KS

General Provider Information

NPI Number	:	1790027563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI A OLIVER PSYD

Provider Business Mailing Address
First Line	:	5500 E KELLOGG DR
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-1607
Country	:	US
Telephone Number	:	316-685-2221
Fax Number	:

Provider Business Practice Location Address
First Line	:	2432 E QUIVIRA CT
Second Line	:
City	:	KECHI
State	:	KS
Zip	:	67067-8909
Country	:	US
Telephone Number	:	301-800-5250
Fax Number	:

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

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	12/17/2018

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