Provider Demographics
NPI:1104330489
Name:GHANNAM, HEATHER (MASTER'S SOCIAL WORK)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:GHANNAM
Suffix:
Gender:F
Credentials:MASTER'S SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HAMPDEN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3116
Mailing Address - Country:US
Mailing Address - Phone:845-764-1398
Mailing Address - Fax:
Practice Address - Street 1:140 HIGH ST STE 230
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1435
Practice Address - Country:US
Practice Address - Phone:413-495-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-25
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health