Provider Demographics
NPI:1881719888
Name:HEFTY, KENNETH EDWARD
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDWARD
Last Name:HEFTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1809
Mailing Address - Country:US
Mailing Address - Phone:315-857-4194
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH COURT RD
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569860Medicaid
NY536220Medicare ID - Type Unspecified