Provider Demographics
NPI:1902920788
Name:HEIDGERKEN, THERESA (LICSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HEIDGERKEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:HEIDGERKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:43 E BROADWAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3046
Mailing Address - Country:US
Mailing Address - Phone:320-631-0007
Mailing Address - Fax:320-631-0007
Practice Address - Street 1:43 E BROADWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3046
Practice Address - Country:US
Practice Address - Phone:320-631-0007
Practice Address - Fax:320-631-0007
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN169701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical