Provider Demographics
NPI:1720853039
Name:PERSONS, HEATHER SUSAN (AMFT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SUSAN
Last Name:PERSONS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23228 MADERO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2706
Mailing Address - Country:US
Mailing Address - Phone:949-454-3940
Mailing Address - Fax:949-770-1953
Practice Address - Street 1:23228 MADERO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2706
Practice Address - Country:US
Practice Address - Phone:949-454-3940
Practice Address - Fax:949-770-1953
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138042106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist