Provider Demographics
NPI:1891409389
Name:HEFFERON, LYDIA JUSTINE (MSW)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:JUSTINE
Last Name:HEFFERON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11035 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2553
Mailing Address - Country:US
Mailing Address - Phone:503-258-4200
Mailing Address - Fax:
Practice Address - Street 1:15455 NW GREENBRIER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7359
Practice Address - Country:US
Practice Address - Phone:503-258-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA14022104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker