Healthcare Provider Details

I. General information

NPI: 1871537696
Provider Name (Legal Business Name): CYNTHIA GRACE HEANEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL RD
WALTON NY
13856-1454
US

IV. Provider business mailing address

1 HOSPITAL RD
WALTON NY
13856-1454
US

V. Phone/Fax

Practice location:
  • Phone: 607-865-6522
  • Fax: 607-865-7424
Mailing address:
  • Phone: 607-865-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1985
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR028299-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: