Provider Demographics
NPI:1790557940
Name:HEAVENRICH, ADAM (LPC-A)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:HEAVENRICH
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 CABLES AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1603
Mailing Address - Country:US
Mailing Address - Phone:203-695-3182
Mailing Address - Fax:
Practice Address - Street 1:228 MEADOW ST STE 403
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1807
Practice Address - Country:US
Practice Address - Phone:203-312-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6817101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional