Provider Demographics
NPI:1548335102
Name:HEINEN, AUDREY RUTH (LISW)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:RUTH
Last Name:HEINEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17030 LEGGETT RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44064-9721
Mailing Address - Country:US
Mailing Address - Phone:440-968-0183
Mailing Address - Fax:
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-285-3568
Practice Address - Fax:440-285-4552
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI73791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical