Provider Demographics
NPI:1912693599
Name:SMALLEY, HEATHER C (CADAC II)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:SMALLEY
Suffix:
Gender:F
Credentials:CADAC II
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:C
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADAC II
Mailing Address - Street 1:9821 CRYSTAL COVE CT
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-2803
Mailing Address - Country:US
Mailing Address - Phone:260-310-9086
Mailing Address - Fax:
Practice Address - Street 1:3282 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2883
Practice Address - Country:US
Practice Address - Phone:812-200-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-51331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)