Healthcare Provider Details

I. General information

NPI: 1750413860
Provider Name (Legal Business Name): ELAINE A. HEFFERNAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RANCHEROS DR
SAN MARCOS CA
92069-2900
US

IV. Provider business mailing address

11840 PASEO LUCIDO #63
SAN DIEGO CA
92128-6229
US

V. Phone/Fax

Practice location:
  • Phone: 760-752-4917
  • Fax: 760-752-4924
Mailing address:
  • Phone: 858-592-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 19280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: