Provider Demographics
NPI:1427509199
Name:HEENAN, JOSHUA (LAC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:HEENAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 COURTLAND AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906
Mailing Address - Country:US
Mailing Address - Phone:203-614-9635
Mailing Address - Fax:
Practice Address - Street 1:316 COURTLAND AVE STE 5
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06906-2269
Practice Address - Country:US
Practice Address - Phone:203-614-9635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2023-07-14
Deactivation Date:2023-05-31
Deactivation Code:
Reactivation Date:2023-07-06
Provider Licenses
StateLicense IDTaxonomies
CO0002816171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist