Provider Demographics
NPI:1487291217
Name:NERESON-BOTT, HEIDI (LLPC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:NERESON-BOTT
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:ENGWERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 HAGUE AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 TROWBRIDGE ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1885
Practice Address - Country:US
Practice Address - Phone:616-499-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional