Healthcare Provider Details

I. General information

NPI: 1902088032
Provider Name (Legal Business Name): MARK DAVID HEANEY L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N LEE AVE SUITE 101
OKLAHOMA CITY OK
73103-2600
US

IV. Provider business mailing address

1111 N LEE AVE SUITE 101
OKLAHOMA CITY OK
73103-2600
US

V. Phone/Fax

Practice location:
  • Phone: 405-820-6992
  • Fax: 405-606-7449
Mailing address:
  • Phone: 405-820-6992
  • Fax: 405-606-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number65976
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3102
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number3102
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: