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General NPI Number Information
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NPI Number | 1457349920
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Entity Type | Individual
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Provider Name | MICHAEL HEFFERNAN PHD CP
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Gender | Male
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Dates
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Enumeration Date | 10/10/2005
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Last Update Date | 08/10/2012
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Provider Practice Location Address
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Address Line | 408 N THIRD STREET
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City | FULTON
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State | TX
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Zip | 78358
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Country | US
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Telephone | 361-463-6115
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2321
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City | FULTON
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State | TX
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Zip | 78358-2321
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Country | US
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Telephone | 361-463-6115
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 22178
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License Number State | TX
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