Healthcare Provider Details

I. General information

NPI: 1588572796
Provider Name (Legal Business Name): BETH ANN HEFFERNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 S GRIFFIN AVE
MILWAUKEE WI
53207-5026
US

IV. Provider business mailing address

521 N STORY PKWY
MILWAUKEE WI
53208-3668
US

V. Phone/Fax

Practice location:
  • Phone: 414-294-1228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: