Healthcare Provider Details

I. General information

NPI: 1962327585
Provider Name (Legal Business Name): MARY ALEXANDRA IRENE HEAVEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CHURCH ST FL 19
NEW HAVEN CT
06510-2100
US

IV. Provider business mailing address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4899
US

V. Phone/Fax

Practice location:
  • Phone: 866-696-0999
  • Fax:
Mailing address:
  • Phone: 631-385-7780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: