Healthcare Provider Details

I. General information

NPI: 1811541311
Provider Name (Legal Business Name): AMANDA MARY HEFFERNAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 857-600-6143
  • Fax:
Mailing address:
  • Phone: 857-600-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098754-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: