Provider Demographics
NPI:1518503358
Name:HEFFERMAN, HOLLIE
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:HEFFERMAN
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 1:37332 SE BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:BORING
Mailing Address - State:OR
Mailing Address - Zip Code:97009-9722
Mailing Address - Country:US
Mailing Address - Phone:503-422-8297
Mailing Address - Fax:
Practice Address - Street 1:4035 SE 52ND AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3913
Practice Address - Country:US
Practice Address - Phone:971-229-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25231225700000X
WA61009426225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist