Provider Demographics
NPI:1588273510
Name:HEINRICH, NATHAN MARK
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:MARK
Last Name:HEINRICH
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 1:831 W SWAIN RD APT L
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4294
Mailing Address - Country:US
Mailing Address - Phone:209-851-0739
Mailing Address - Fax:
Practice Address - Street 1:1111 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1509
Practice Address - Country:US
Practice Address - Phone:415-863-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10823101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)