MEDICARE: MS. MARY KATHERINE CAMPBELL HEFFERNAN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT25937	FL
2	225100000X	Physical Therapist	6652	SC

General Provider Information

NPI Number	:	1548560691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHERINE CAMPBELL HEFFERNAN PT

Provider Business Mailing Address
First Line	:	1011 GROVE RD
Second Line	:	SUITE 2-A
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4660
Country	:	US
Telephone Number	:	864-233-5128
Fax Number	:	864-271-2599

Provider Business Practice Location Address
First Line	:	1011 GROVE RD
Second Line	:	SUITE 2-A
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4660
Country	:	US
Telephone Number	:	864-233-5128
Fax Number	:	864-271-2599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	10/23/2012

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