Provider Demographics
NPI:1174035943
Name:HOFMANN, HEATHER ANN
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:HOFMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 E WORTHY ST STE B-2
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4302
Mailing Address - Country:US
Mailing Address - Phone:225-258-7322
Mailing Address - Fax:225-450-3799
Practice Address - Street 1:1058 E WORTHY ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4302
Practice Address - Country:US
Practice Address - Phone:225-258-7322
Practice Address - Fax:225-450-3799
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LABH0012108251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA81-5326332Medicaid