Provider Demographics
NPI:1154596617
Name:WEDGLE, HEATHER EVE (PSYD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:EVE
Last Name:WEDGLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-1524
Mailing Address - Country:US
Mailing Address - Phone:720-581-4620
Mailing Address - Fax:303-923-8600
Practice Address - Street 1:4495 HALE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-6203
Practice Address - Country:US
Practice Address - Phone:720-581-4620
Practice Address - Fax:303-923-8600
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12089362OtherCAQH PIN
COPSY.0003350OtherPROFESSIONAL LICENSE
CO12089362OtherCAQH PIN
CO22633235Medicaid