Provider Demographics
NPI:1679584783
Name:HEIZENROTH, WALTER
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:HEIZENROTH
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 1:6 WOODVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-2119
Mailing Address - Country:US
Mailing Address - Phone:610-948-0981
Mailing Address - Fax:610-948-1464
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:610-384-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005637L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling