Provider Demographics
NPI:1316990880
Name:HEARTLAND CLINIC, INC.
Entity type:Organization
Organization Name:HEARTLAND CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:765-446-9898
Mailing Address - Street 1:2201 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3047
Mailing Address - Country:US
Mailing Address - Phone:765-446-9898
Mailing Address - Fax:765-446-9424
Practice Address - Street 1:2201 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3047
Practice Address - Country:US
Practice Address - Phone:765-446-9898
Practice Address - Fax:765-446-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001121A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty