Healthcare Provider Details

I. General information

NPI: 1053859553
Provider Name (Legal Business Name): MICHAEL HEAVEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EMERSON ST
MANCHESTER CT
06040-4906
US

IV. Provider business mailing address

12 EMERSON ST
MANCHESTER CT
06040-4906
US

V. Phone/Fax

Practice location:
  • Phone: 860-969-7119
  • Fax:
Mailing address:
  • Phone: 860-969-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: