Healthcare Provider Details

I. General information

NPI: 1447845458
Provider Name (Legal Business Name): HEATHER A BACON, PH.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 SE 2ND ST STE A
HERMISTON OR
97838-2486
US

IV. Provider business mailing address

230 SE 2ND ST STE A
HERMISTON OR
97838-2486
US

V. Phone/Fax

Practice location:
  • Phone: 541-289-7777
  • Fax: 541-289-7778
Mailing address:
  • Phone: 541-289-7777
  • Fax: 541-289-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HEATHER BACON
Title or Position: OWNER
Credential: PH.D.
Phone: 541-289-7777