| Doctor Name: | HEIDI NICEWANDER |
| NPI Number: | 1023414463 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | L6300 |
| Business Practice Address: | 4545 Se Ina Ave Apt 9 Milwaukie, OR - 972675918 |
| Business Phone Number: | 5036545678 |
| Business Fax Number: | 5039543409 |
| Mailing Address: | 3587 Heathrow Way, MEDFORD |
| State: | OR |
| Postal Code: | 975044004 |
| Phone Number: | 7346440745 |
| Fax Number: | |
| NPI Enumeration Date: | 11/12/2014 |
| NPI Last Update Date: | 02/25/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | L6300 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |