Provider Demographics
NPI:1730238460
Name:VAN DER HEIDE, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:VAN DER HEIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9012 BURTON WAY
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1618
Mailing Address - Country:US
Mailing Address - Phone:310-859-7849
Mailing Address - Fax:
Practice Address - Street 1:9012 BURTON WAY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1618
Practice Address - Country:US
Practice Address - Phone:310-859-7849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16232103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical