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General NPI Number Information
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NPI Number | 1639307622
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Entity Type | Organization
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Legal Business Name | NICOLE HEFFRON, LLC
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Dates
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Enumeration Date | 06/29/2009
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Last Update Date | 06/29/2009
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Provider Practice Location Address
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Address Line | 889 GRAND AVE SUITE 202
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City | SAINT PAUL
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State | MN
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Zip | 55105-3008
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Country | US
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Telephone | 651-224-1541
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Fax | 651-224-3501
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Provider Business Mailing Address
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Address Line | 889 GRAND AVE SUITE 202
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City | SAINT PAUL
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State | MN
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Zip | 55105-3008
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Country | US
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Telephone | 651-224-1541
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Fax | 651-224-3501
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | MS. NICOLE ENGLUND HEFFRON
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Credential | PH.D.
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Telephone | 651-224-1541
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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 | LP 4508
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License Number State | MN
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