Provider Demographics
NPI:1821213703
Name:HERITAGE, SHAMA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHAMA
Middle Name:MARIE
Last Name:HERITAGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 FOXBOROUGH TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-2904
Mailing Address - Country:US
Mailing Address - Phone:817-366-1075
Mailing Address - Fax:
Practice Address - Street 1:4207 FOXBOROUGH TRL
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-2904
Practice Address - Country:US
Practice Address - Phone:817-366-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX614080Medicare PIN