Provider Demographics
NPI:1831252881
Name:HEATHERLY, MATT (LMFT)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HEATHERLY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8492 ENCLAVE BLVD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1591
Mailing Address - Country:US
Mailing Address - Phone:317-721-4123
Mailing Address - Fax:
Practice Address - Street 1:8492 ENCLAVE BLVD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1591
Practice Address - Country:US
Practice Address - Phone:317-721-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN100270530AMedicaid