Provider Demographics
NPI:1861208530
Name:VAN HEERDEN, MARTHINUS GODFRID
Entity type:Individual
Prefix:
First Name:MARTHINUS
Middle Name:GODFRID
Last Name:VAN HEERDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 W FRONTAGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1209
Mailing Address - Country:US
Mailing Address - Phone:312-780-0820
Mailing Address - Fax:877-716-4799
Practice Address - Street 1:778 W FRONTAGE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1209
Practice Address - Country:US
Practice Address - Phone:312-780-0820
Practice Address - Fax:877-716-4799
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician