Provider Demographics
NPI:1588738603
Name:HEFFERNAN, MICHAEL (LICSW, LCDP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:LICSW, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 NORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5812
Mailing Address - Country:US
Mailing Address - Phone:401-941-0804
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-421-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP 00193101YA0400X
RIISW 003581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI205032OtherRI BLUECROSS-BLUECHIP
RI62-52319OtherUNITEDBEHAVIORALHEALTH
RI23588-4OtherRI BLUECROSS-BLUESHIELD