Basic Information
| Provider Information | |||||||||
| NPI: | 1124552278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEFFERAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | LMSW, MPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11652 W GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493318465 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2017 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801100865 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 1041C0700X | 6801104870 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.