Healthcare Provider Details

I. General information

NPI: 1255655411
Provider Name (Legal Business Name): GLENDA L. HEYWARD MSW, LCAS-A, QP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 TRADEWINDS DR
FAYETTEVILLE NC
28314-2467
US

IV. Provider business mailing address

508 TRADEWINDS DR
FAYETTEVILLE NC
28314-2467
US

V. Phone/Fax

Practice location:
  • Phone: 910-489-2404
  • Fax:
Mailing address:
  • Phone: 910-489-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP004978
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: