Provider Demographics
NPI:1679511794
Name:BREITER, HEATHER DENISE
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:DENISE
Last Name:BREITER
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 1:6824 GLEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3734
Mailing Address - Country:US
Mailing Address - Phone:817-370-8644
Mailing Address - Fax:
Practice Address - Street 1:2129 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1924
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167469901Medicaid
TX86932AOtherBLUE CROSS BLUE SHIELD
TXP00163676OtherRAIL ROAD
TXP00163676OtherRAIL ROAD