Provider Demographics
NPI:1962501841
Name:HEFFERNAN, ELAINE MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 FEDERAL ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1703
Mailing Address - Country:US
Mailing Address - Phone:617-724-8232
Mailing Address - Fax:
Practice Address - Street 1:133 FEDERAL ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1703
Practice Address - Country:US
Practice Address - Phone:617-724-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10277291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1892754Medicaid
MAP20499Medicare ID - Type Unspecified