Healthcare Provider Details

I. General information

NPI: 1356461487
Provider Name (Legal Business Name): KATHLEEN MARY HEFFERNAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 N 79TH AVE B-45
GLENDALE AZ
85308-8388
US

IV. Provider business mailing address

2753 E WINDROSE DR
PHOENIX AZ
85032-6932
US

V. Phone/Fax

Practice location:
  • Phone: 602-770-4188
  • Fax: 623-334-6724
Mailing address:
  • Phone: 602-770-4188
  • Fax: 623-334-6724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-1748
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: