Provider Demographics
NPI:1316606437
Name:HIEMSTRA, ANDREW ROBERT
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROBERT
Last Name:HIEMSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 N GILBERT RD STE C100
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4736
Mailing Address - Country:US
Mailing Address - Phone:480-734-3851
Mailing Address - Fax:
Practice Address - Street 1:459 N GILBERT RD STE C100
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4736
Practice Address - Country:US
Practice Address - Phone:480-734-3851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15475106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1225206444Medicaid