Provider Demographics
NPI:1154964872
Name:HEAVIN, CAROL SUE (LAC, TA)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:HEAVIN
Suffix:
Gender:F
Credentials:LAC, TA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 HEINKE RD
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-2048
Mailing Address - Country:US
Mailing Address - Phone:501-455-5793
Mailing Address - Fax:
Practice Address - Street 1:10500 WOODMAN ST
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-1789
Practice Address - Country:US
Practice Address - Phone:501-247-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1707234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health