Provider Demographics
NPI:1356461487
Name:HEFFERNAN, KATHLEEN MARY (LPC)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 E WINDROSE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-6932
Mailing Address - Country:US
Mailing Address - Phone:602-770-4188
Mailing Address - Fax:623-334-6724
Practice Address - Street 1:18001 N 79TH AVE
Practice Address - Street 2:B-45
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8388
Practice Address - Country:US
Practice Address - Phone:602-770-4188
Practice Address - Fax:623-334-6724
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ806309Medicaid