=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386840205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER LYNETTE CONKLIN MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1577 PAYNE AVE
-----------------------------------------------------
City | EDWARDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-860-2054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3648 JASMINE AVE
-----------------------------------------------------
City | ROSAMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-860-2054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT90317
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------