Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP2500X | Professional Counselor | ||
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist |
NPI | 1013147958 |
---|---|
Provider Name | Dr. Amanda Marie Heins |
First Address | Brown Deer, WI 53223-1475 |
Second Address | Brown Deer, WI 53223-1475 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2009 |
Last Update Date | 01/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101314758 | (05) | WI |
12317640 | CAQH (01) | WI |