Provider Demographics
NPI:1457349920
Name:HEFFERNAN, MICHAEL (PHD CP)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:PHD CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2321
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:TX
Mailing Address - Zip Code:78358-2321
Mailing Address - Country:US
Mailing Address - Phone:361-463-6115
Mailing Address - Fax:
Practice Address - Street 1:408 N THIRD STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:TX
Practice Address - Zip Code:78358
Practice Address - Country:US
Practice Address - Phone:361-463-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22178103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035457301Medicaid
TX035457301Medicaid
R58815Medicare UPIN