Provider Demographics
NPI:1225167398
Name:HEENAN, PHYLLIS C (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:HEENAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3401
Mailing Address - Country:US
Mailing Address - Phone:831-428-3771
Mailing Address - Fax:
Practice Address - Street 1:47 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3401
Practice Address - Country:US
Practice Address - Phone:831-428-3771
Practice Address - Fax:831-661-5197
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW90571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION43870Medicare ID - Type Unspecified