Provider Demographics
NPI:1558093963
Name:IRENE, HEATHER I (MS, LBS)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:I
Last Name:IRENE
Suffix:
Gender:F
Credentials:MS, LBS
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:IRENE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBS
Mailing Address - Street 1:793 OLD ROUTE 119 HIGHWAY NORTH
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-465-5576
Mailing Address - Fax:
Practice Address - Street 1:793 OLD ROUTE 119 HIGHWAY NORTH
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-465-5576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005404101YM0800X
PA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician