Provider Demographics
NPI:1174331714
Name:HEIDEBCRECHT, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HEIDEBCRECHT
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 1:6166 DILL CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95215-1003
Mailing Address - Country:US
Mailing Address - Phone:209-616-7931
Mailing Address - Fax:
Practice Address - Street 1:6166 DILL CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-1003
Practice Address - Country:US
Practice Address - Phone:209-616-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-388469106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician