Healthcare Provider Details

I. General information

NPI: 1093087850
Provider Name (Legal Business Name): PAUL M HEFFINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 VARDEN DR #B
AIKEN SC
29803-5285
US

IV. Provider business mailing address

33 VARDEN DR #B
AIKEN SC
29803-5285
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-3801
  • Fax:
Mailing address:
  • Phone: 803-642-3801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number18139
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1112
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: