Healthcare Provider Details

I. General information

NPI: 1790187045
Provider Name (Legal Business Name): MARISUE HEFFNER MA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 GENTILLY RD
STATESBORO GA
30458-5149
US

IV. Provider business mailing address

518 GENTILLY RD
STATESBORO GA
30458-5149
US

V. Phone/Fax

Practice location:
  • Phone: 612-681-7768
  • Fax: 912-681-7782
Mailing address:
  • Phone: 612-681-7768
  • Fax: 912-681-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP008690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: