Provider Demographics
NPI:1295221612
Name:PROVENCE, HEATHER LYNNE (PMHNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNNE
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:890 MOUNTAIN AVE
Practice Address - Street 2:BEHAVIORAL HEALTH & COGNITIVE THERAPY
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974
Practice Address - Country:US
Practice Address - Phone:908-277-8900
Practice Address - Fax:908-508-8919
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402394-1363LP0808X
NJ26NJ01289400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05265370Medicaid