Provider Demographics
NPI:1154820710
Name:HEFFNER, BROOKE HALEY (CDCA, QMHS)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:HALEY
Last Name:HEFFNER
Suffix:
Gender:F
Credentials:CDCA, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1235
Mailing Address - Country:US
Mailing Address - Phone:740-442-7045
Mailing Address - Fax:
Practice Address - Street 1:1007 N 2ND ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1235
Practice Address - Country:US
Practice Address - Phone:740-442-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0282406Medicaid