Provider Demographics
NPI:1366513178
Name:HEFFERNAN, MARK C (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2128
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1055
Mailing Address - Country:US
Mailing Address - Phone:760-902-6226
Mailing Address - Fax:760-770-6673
Practice Address - Street 1:47 PROVENCE WAY
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2727
Practice Address - Country:US
Practice Address - Phone:760-902-6226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14471103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL144710Medicare ID - Type Unspecified