Provider Demographics
NPI:1760784300
Name:DEVINE, HEATHER (IMF)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W 1ST ST STE 230
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4744
Mailing Address - Country:US
Mailing Address - Phone:909-624-1997
Mailing Address - Fax:909-624-4409
Practice Address - Street 1:250 W 1ST ST STE 230
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4744
Practice Address - Country:US
Practice Address - Phone:909-624-1997
Practice Address - Fax:909-624-4409
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 58154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist