Provider Demographics
NPI:1457086688
Name:HEFNER, DEREK LYNN (CAPSW)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LYNN
Last Name:HEFNER
Suffix:
Gender:M
Credentials:CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 SHERMAN AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5983
Mailing Address - Country:US
Mailing Address - Phone:423-737-7933
Mailing Address - Fax:
Practice Address - Street 1:1915 SHERMAN AVE APT 18
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5983
Practice Address - Country:US
Practice Address - Phone:423-737-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132697-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical