Provider Demographics
NPI:1386259158
Name:HEISELBETZ, HAILEE ANN
Entity type:Individual
Prefix:MISS
First Name:HAILEE
Middle Name:ANN
Last Name:HEISELBETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55-107 NAUPAKA ST
Mailing Address - Street 2:
Mailing Address - City:LAIE
Mailing Address - State:HI
Mailing Address - Zip Code:96762-1130
Mailing Address - Country:US
Mailing Address - Phone:702-412-6778
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE. STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician