Healthcare Provider Details

I. General information

NPI: 1144191610
Provider Name (Legal Business Name): MARK HEFFERNAN LCADC, LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 S LITTLE ROCK AVE APT A
VENTNOR CITY NJ
08406-2802
US

IV. Provider business mailing address

17 S LITTLE ROCK AVE APT A
VENTNOR CITY NJ
08406-2802
US

V. Phone/Fax

Practice location:
  • Phone: 856-693-9188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37LC00408900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: