MEDICARE: DR. HEIDI DAWN 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	5430	NC
2	103TC0700X	Clinical Psychologist	1528	SC
3	103TC0700X	Clinical Psychologist	17115	CA
4	103T00000X	Psychologist	17115	CA

General Provider Information

NPI Number	:	1952812752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEIDI DAWN PSYD

Provider Business Mailing Address
First Line	:	PO BOX 2512
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-4000
Country	:	US
Telephone Number	:	803-200-2601
Fax Number	:	803-961-6600

Provider Business Practice Location Address
First Line	:	1331 ELMWOOD AVE STE 300B
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-2150
Country	:	US
Telephone Number	:	803-200-2601
Fax Number	:	803-961-6600

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

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	10/06/2025

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