Provider Demographics
NPI:1871005108
Name:HEYDORN, KATHRYN R
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:HEYDORN
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 1:7714 E WILLARD DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8252
Mailing Address - Country:US
Mailing Address - Phone:208-810-1276
Mailing Address - Fax:208-895-8049
Practice Address - Street 1:7714 E WILLARD DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8252
Practice Address - Country:US
Practice Address - Phone:208-810-1276
Practice Address - Fax:208-895-8049
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60789946101YM0800X
WAMC60789946101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871005108OtherNPI