Provider Demographics
NPI:1215314414
Name:HEARTSOURCE THERAPY PC
Entity type:Organization
Organization Name:HEARTSOURCE THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIENHUIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-837-3319
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0523
Mailing Address - Country:US
Mailing Address - Phone:708-837-3319
Mailing Address - Fax:815-469-6481
Practice Address - Street 1:33 E COLORADO AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1385
Practice Address - Country:US
Practice Address - Phone:708-837-3319
Practice Address - Fax:815-469-6481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490144841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty