Provider Demographics
NPI:1902148059
Name:HEITZMANN, ELIZABETH LOUISE (MAC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:LOUISE
Last Name:HEITZMANN
Suffix:
Gender:F
Credentials:MAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S PIER DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4986
Mailing Address - Country:US
Mailing Address - Phone:920-698-0019
Mailing Address - Fax:920-208-7060
Practice Address - Street 1:640 S PIER DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4986
Practice Address - Country:US
Practice Address - Phone:920-698-0019
Practice Address - Fax:920-803-0337
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
WI5630-125103TC1900X
WI1642-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000032020Medicaid