Provider Demographics
NPI:1023827797
Name:HENDRICKSON, HEIDI MAE (CO61594980)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MAE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:CO61594980
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 SW CASCADE AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2913
Mailing Address - Country:US
Mailing Address - Phone:503-453-9352
Mailing Address - Fax:
Practice Address - Street 1:505 SE ADAMS AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3031
Practice Address - Country:US
Practice Address - Phone:360-266-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61594980101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)