Healthcare Provider Details

I. General information

NPI: 1700190816
Provider Name (Legal Business Name): GARY JAMES HEFFNER M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY UPTOWN DIVISION - ROOM 1E114
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

1 FREEDOM WAY UPTOWN DIVISION - ROOM 1E114
AUGUSTA GA
30904-6258
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 706-733-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: