Provider Demographics
NPI:1487165072
Name:MANDEVILLE, HEATHER B (LICSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:B
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:B
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:135 GOLD STAR BLVD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2738
Mailing Address - Country:US
Mailing Address - Phone:508-459-6400
Mailing Address - Fax:508-849-5618
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2738
Practice Address - Country:US
Practice Address - Phone:508-459-6400
Practice Address - Fax:508-849-5618
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW124058101YM0800X
101YM0800X
MALCSW224417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health