Healthcare Provider Details

I. General information

NPI: 1689055048
Provider Name (Legal Business Name): PHIL HEFFERNAN MHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 MAIN ST
BEACON NY
12508-2770
US

IV. Provider business mailing address

230 NORTH RD
POUGHKEEPSIE NY
12601-1328
US

V. Phone/Fax

Practice location:
  • Phone: 845-838-4900
  • Fax:
Mailing address:
  • Phone: 845-838-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP96769
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: