Provider Demographics
NPI:1548560691
Name:HEFFERNAN, MARY KATHERINE CAMPBELL (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY KATHERINE
Middle Name:CAMPBELL
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY KATHERINE
Other - Middle Name:OLYVIA
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1011 GROVE RD
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4660
Mailing Address - Country:US
Mailing Address - Phone:864-233-5128
Mailing Address - Fax:864-271-2599
Practice Address - Street 1:1011 GROVE RD
Practice Address - Street 2:SUITE 2-A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4660
Practice Address - Country:US
Practice Address - Phone:864-233-5128
Practice Address - Fax:864-271-2599
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25937174400000X
SC6652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist