Provider Demographics
NPI:1689003147
Name:HEATHERLY, JOE III (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:HEATHERLY
Suffix:III
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4018
Mailing Address - Country:US
Mailing Address - Phone:479-636-0083
Mailing Address - Fax:479-636-0144
Practice Address - Street 1:114 E CRANDALL AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3628
Practice Address - Country:US
Practice Address - Phone:870-741-8484
Practice Address - Fax:870-741-4088
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2107009101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199054795Medicaid