Healthcare Provider Details

I. General information

NPI: 1730169913
Provider Name (Legal Business Name): MICHAEL K. O'HEARN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1862 PLAZA DEL SUR DR APT 147
SANTA FE NM
87505-6046
US

IV. Provider business mailing address

1862 PLAZA DEL SUR DR APT 147
SANTA FE NM
87505-6046
US

V. Phone/Fax

Practice location:
  • Phone: 513-766-2496
  • Fax:
Mailing address:
  • Phone: 505-955-9454
  • Fax: 505-216-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1.0007335
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0525
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number98193
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0007335-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: