MEDICARE: DR. ELIZABETH ANN HERON PHD

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	103G00000X	Clinical Neuropsychologist	PSY 10917	CA
2	103TC0700X	Clinical Psychologist	PSY 10917	CA

General Provider Information

NPI Number	:	1700857612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH ANN HERON PHD

Provider Business Mailing Address
First Line	:	8929 WILLMON WAY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78239-1948
Country	:	US
Telephone Number	:	210-671-5693
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 BERGQUIST DR STE 1
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-9908
Country	:	US
Telephone Number	:	210-671-2032
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	02/26/2008

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