Provider Demographics
NPI:1679985873
Name:DANNISON, HEATHER JANE (PHD, LP, LPC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JANE
Last Name:DANNISON
Suffix:
Gender:F
Credentials:PHD, LP, LPC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JANE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:604 S ROSE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5273
Mailing Address - Country:US
Mailing Address - Phone:517-256-8476
Mailing Address - Fax:
Practice Address - Street 1:4029 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2763
Practice Address - Country:US
Practice Address - Phone:269-692-5321
Practice Address - Fax:269-312-7328
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014264101Y00000X
MI6301016125103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679985873OtherNPI 1