Provider Demographics
NPI:1376780437
Name:HEEREN, ROGER
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HEEREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 LODGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-7452
Mailing Address - Country:US
Mailing Address - Phone:512-635-3544
Mailing Address - Fax:
Practice Address - Street 1:12255 LODGE RD
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NC
Practice Address - Zip Code:27557-7452
Practice Address - Country:US
Practice Address - Phone:512-635-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2229106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist