Provider Demographics
NPI:1649615089
Name:BACON, HEATHER A (PHD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:BACON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SE 2ND STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838
Mailing Address - Country:US
Mailing Address - Phone:541-289-7777
Mailing Address - Fax:541-289-7778
Practice Address - Street 1:230 SE 2ND ST STE A
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2486
Practice Address - Country:US
Practice Address - Phone:541-289-7777
Practice Address - Fax:541-289-7778
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical