1215149240 NPI number — MS. ANDREA DURANT HEITZ L.C.S.W.

Table of content: MS. ANDREA DURANT HEITZ L.C.S.W. (NPI 1215149240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215149240 NPI number — MS. ANDREA DURANT HEITZ L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEITZ
Provider First Name:
ANDREA
Provider Middle Name:
DURANT
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215149240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MONTE DIABLO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91766-4778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-438-4554
Provider Business Mailing Address Fax Number:
909-620-5694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 N INDIAN HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLAREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91711-4644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-438-4554
Provider Business Practice Location Address Fax Number:
909-620-5694
Provider Enumeration Date:
05/03/2007

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:  LCS 22697 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22697 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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