Provider Demographics
NPI:1346801990
Name:HEIFNER, GWEN
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:HEIFNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ROYCE RD STE 12
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1409
Mailing Address - Country:US
Mailing Address - Phone:312-882-1024
Mailing Address - Fax:312-488-3663
Practice Address - Street 1:101 ROYCE RD STE 12
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1409
Practice Address - Country:US
Practice Address - Phone:312-882-1024
Practice Address - Fax:312-488-3663
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-19-35201103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst