Provider Demographics
NPI:1225459373
Name:HEFFERNAN, SHANNON (LSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:ST. JOSEPH'S CHILDREN'S HOSPITAL, XAVIER 7
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-3463
Mailing Address - Fax:973-754-3331
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:ST. JOSEPH'S CHILDREN'S HOSPITAL, XAVIER 7
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-3463
Practice Address - Fax:973-754-3331
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05111400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker