Basic Information
| Provider Information | |||||||||
| NPI: | 1104330489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHANNAM | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MASTER'S SOCIAL WORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 HAMPDEN ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010893116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457641398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 140 HIGH ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011051435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134951500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2017 | ||||||||
| LastUpdateDate: | 11/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.