Provider Demographics
NPI:1588780480
Name:HEIDER, MARYANN (MED CCCA)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:HEIDER
Suffix:
Gender:F
Credentials:MED CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:937-435-7476
Mailing Address - Fax:937-435-6666
Practice Address - Street 1:255 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-435-7476
Practice Address - Fax:937-435-6666
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA00547231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000321651OtherANTHEM