Healthcare Provider Details

I. General information

NPI: 1225337686
Provider Name (Legal Business Name): LARA HEFLIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CALIENTE RD UNIT 1
SANTA FE NM
87508-9209
US

IV. Provider business mailing address

28 ENCANTADO RD
SANTA FE NM
87508-1394
US

V. Phone/Fax

Practice location:
  • Phone: 323-620-2834
  • Fax:
Mailing address:
  • Phone: 323-620-2834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1292
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: