Provider Demographics
NPI:1104900059
Name:FENTON, HEIDI (MA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401
Mailing Address - Country:US
Mailing Address - Phone:505-461-8639
Mailing Address - Fax:
Practice Address - Street 1:280 1ST ST BLDG 23
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-063061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical