1376584847 NPI number — HEIDI J PENDLETON MSW LCSW

Table of content: HEIDI J PENDLETON MSW LCSW (NPI 1376584847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376584847 NPI number — HEIDI J PENDLETON MSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENDLETON
Provider First Name:
HEIDI
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAUER
Provider Other First Name:
HEIDI
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376584847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53901-0301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-742-5518
Provider Business Mailing Address Fax Number:
608-268-9780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 BUTTS AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54660-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-372-5999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7188 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40939200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".