Provider Demographics
NPI:1699840348
Name:HEFFERNAN, STACEY M (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:PEDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-3766
Mailing Address - Country:US
Mailing Address - Phone:781-229-8011
Mailing Address - Fax:781-229-8374
Practice Address - Street 1:100 CUMMINGS CTR
Practice Address - Street 2:SUITE 121Q
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6115
Practice Address - Country:US
Practice Address - Phone:978-927-0907
Practice Address - Fax:978-927-0537
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist