Provider Demographics
NPI:1851960371
Name:HEATLEY, MEDALIA ALEXIS
Entity Type:Individual
Prefix:
First Name:MEDALIA
Middle Name:ALEXIS
Last Name:HEATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-2363
Mailing Address - Country:US
Mailing Address - Phone:413-273-2995
Mailing Address - Fax:
Practice Address - Street 1:77 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2363
Practice Address - Country:US
Practice Address - Phone:413-273-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician