Provider Demographics
NPI:1548336993
Name:DAHLBORG, HEIDI SUSAN (LM)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:SUSAN
Last Name:DAHLBORG
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-6223
Mailing Address - Country:US
Mailing Address - Phone:941-726-8203
Mailing Address - Fax:
Practice Address - Street 1:5353 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-6223
Practice Address - Country:US
Practice Address - Phone:941-726-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW123175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3404404Medicaid