Provider Demographics
NPI:1831549955
Name:HINES, HEATHER (PHD, LCSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7558 KACHINA LOOP
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4042
Mailing Address - Country:US
Mailing Address - Phone:518-428-6881
Mailing Address - Fax:
Practice Address - Street 1:7558 KACHINA LOOP
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4042
Practice Address - Country:US
Practice Address - Phone:518-428-6881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 104100000X
NMC-104391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1467037267Medicaid
NM35588519Medicaid