Healthcare Provider Details

I. General information

NPI: 1255944526
Provider Name (Legal Business Name): LAURA K HEFFERNAN MA, LCPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 ARBOR LAKES DR
DAVENPORT FL
33896-8170
US

IV. Provider business mailing address

372 ARBOR LAKES DR
DAVENPORT FL
33896-8170
US

V. Phone/Fax

Practice location:
  • Phone: 630-709-8820
  • Fax:
Mailing address:
  • Phone: 630-709-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.010352
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH16779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: