MEDICARE: THERESA HEIDGERKEN 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	1041C0700X	Clinical Social Worker	16970	MN

General Provider Information

NPI Number	:	1902920788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA HEIDGERKEN LICSW

Provider Business Mailing Address
First Line	:	43 E BROADWAY
Second Line	:	SUITE 102
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-3046
Country	:	US
Telephone Number	:	320-631-0007
Fax Number	:	320-631-0007

Provider Business Practice Location Address
First Line	:	43 E BROADWAY
Second Line	:	SUITE 102
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-3046
Country	:	US
Telephone Number	:	320-631-0007
Fax Number	:	320-631-0007

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	09/30/2010

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