Healthcare Provider Details

I. General information

NPI: 1083614424
Provider Name (Legal Business Name): PHYLLIS JEAN HEFFNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 HICKORY RIDGE RD STE 215
COLUMBIA MD
21044-3871
US

IV. Provider business mailing address

10801 HICKORY RIDGE RD STE 215
COLUMBIA MD
21044-3871
US

V. Phone/Fax

Practice location:
  • Phone: 410-260-0344
  • Fax: 410-260-0344
Mailing address:
  • Phone: 410-260-0344
  • Fax: 410-260-0344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0038523
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0038523
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: