Provider Demographics
NPI:1386155356
Name:HEIDTKE, LISETTE T (LPC)
Entity type:Individual
Prefix:MS
First Name:LISETTE
Middle Name:T
Last Name:HEIDTKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 NW YEON AVE
Mailing Address - Street 2:PMB 400
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-1519
Mailing Address - Country:US
Mailing Address - Phone:269-598-5152
Mailing Address - Fax:208-834-3164
Practice Address - Street 1:2120 NE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4306
Practice Address - Country:US
Practice Address - Phone:269-598-5152
Practice Address - Fax:208-834-3164
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6716101Y00000X, 101YM0800X, 101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health