Provider Demographics
NPI:1073083622
Name:HEAVEN, MARY LOUANNA (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUANNA
Last Name:HEAVEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HEUSTED DR
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-1918
Mailing Address - Country:US
Mailing Address - Phone:203-536-3865
Mailing Address - Fax:
Practice Address - Street 1:3 HEUSTED DR
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1918
Practice Address - Country:US
Practice Address - Phone:203-536-3865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0696171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist