Provider Demographics
NPI:1396290144
Name:HEFFERNAN, MATTHEW (OTR/L)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 CLARKE ST APT B
Mailing Address - Street 2:NONE
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2783
Mailing Address - Country:US
Mailing Address - Phone:209-380-5122
Mailing Address - Fax:
Practice Address - Street 1:3830 CLARKE ST APT B
Practice Address - Street 2:NONE
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2783
Practice Address - Country:US
Practice Address - Phone:209-380-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16517225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist