Provider Demographics
NPI:1528424488
Name:DIRKSE-GRAW, HEIDI ANNETTE (LPC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ANNETTE
Last Name:DIRKSE-GRAW
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 1:4618 CLOUDCREST DR STE 320
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9050
Mailing Address - Country:US
Mailing Address - Phone:503-516-8073
Mailing Address - Fax:202-788-6366
Practice Address - Street 1:16 N RIVERSIDE AVE STE 209
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6024
Practice Address - Country:US
Practice Address - Phone:503-516-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497461669OtherNPI NUMERATOR
OR500711141Medicaid