Provider Demographics
NPI:1124627575
Name:BLACK, HEATHER LEIGH (LPCA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LAKEVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3442
Mailing Address - Country:US
Mailing Address - Phone:860-559-6543
Mailing Address - Fax:
Practice Address - Street 1:12 LAKEVIEW BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3442
Practice Address - Country:US
Practice Address - Phone:860-559-6543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health