Provider Demographics
NPI:1568671477
Name:HEERY, MYRTLE WISE (PHD, MFT)
Entity type:Individual
Prefix:MRS
First Name:MYRTLE
Middle Name:WISE
Last Name:HEERY
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 BODEGA AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-9685
Mailing Address - Country:US
Mailing Address - Phone:707-763-3808
Mailing Address - Fax:707-778-7074
Practice Address - Street 1:4940 BODEGA AVE
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-9685
Practice Address - Country:US
Practice Address - Phone:707-763-3808
Practice Address - Fax:707-778-7074
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist