Healthcare Provider Details

I. General information

NPI: 1649593955
Provider Name (Legal Business Name): MRS. LINDA HEFLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 ASHMOOR AVE
BOWLING GREEN KY
42101-3702
US

IV. Provider business mailing address

543 ASHMOOR AVE
BOWLING GREEN KY
42101-3702
US

V. Phone/Fax

Practice location:
  • Phone: 270-796-4062
  • Fax: 270-796-4062
Mailing address:
  • Phone: 270-796-4062
  • Fax: 270-796-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberF19527M
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: