Provider Demographics
NPI:1417992298
Name:HEEGEL, CLIFFORD RAMBO (PHD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:RAMBO
Last Name:HEEGEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 SPOTTSWOOD AVE
Mailing Address - Street 2:#361
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4817
Mailing Address - Country:US
Mailing Address - Phone:901-763-0999
Mailing Address - Fax:
Practice Address - Street 1:4728 SPOTTSWOOD AVE
Practice Address - Street 2:#361
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4817
Practice Address - Country:US
Practice Address - Phone:901-763-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP001687103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688272Medicaid
TNP001687OtherPSYCHOLOGY LICENSE
TN3688272Medicaid