Provider Demographics
NPI:1831102839
Name:HEFFRON, NICOLE ENGLUND (NICOLE HEFFRON)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ENGLUND
Last Name:HEFFRON
Suffix:
Gender:F
Credentials:NICOLE HEFFRON
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:ENGLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1123 GRAND AVE
Mailing Address - Street 2:201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2629
Mailing Address - Country:US
Mailing Address - Phone:651-224-1541
Mailing Address - Fax:
Practice Address - Street 1:1123 GRAND AVE
Practice Address - Street 2:201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2629
Practice Address - Country:US
Practice Address - Phone:651-224-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN148445100Medicaid
MN322L4HEOtherBLUE CROSS BLUE SHIELD
MN572G1ENOtherBLUE CROSS BLUE SHEILD