Provider Demographics
NPI:1912922832
Name:RHODES, HEATHER A (MS)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:RHODES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:COLERAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55722-0607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 S POKEGAMA AVE STE 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4296
Practice Address - Country:US
Practice Address - Phone:218-327-0887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3017101YM0800X, 103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN402817100Medicaid
MNLP3017OtherBOARD OF PSYCH. LICENSE #
MN83A52RHOtherBCBS PROVIDER ID
MN62-05533OtherUBH PROVIDER ID