Provider Demographics
NPI:1699559567
Name:VAN BRACKEL, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:VAN BRACKEL
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 1:2421 ARAPAHO WAY
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1627
Mailing Address - Country:US
Mailing Address - Phone:610-585-9136
Mailing Address - Fax:
Practice Address - Street 1:8229 CLOVERLEAF DR STE 425
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1594
Practice Address - Country:US
Practice Address - Phone:443-599-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor