Provider Demographics
NPI:1902676810
Name:MATHIESON, HEATHER RENEE (PLPC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RENEE
Last Name:MATHIESON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:RENEE
Other - Last Name:NICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10079 DEER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CADET
Mailing Address - State:MO
Mailing Address - Zip Code:63630-9468
Mailing Address - Country:US
Mailing Address - Phone:573-854-7830
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023046468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health