Provider Demographics
NPI:1174112072
Name:HEFFERNAN, EMORY WILLIAM (PSI)
Entity type:Individual
Prefix:
First Name:EMORY
Middle Name:WILLIAM
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:PSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COX ST APT 34
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36832-7708
Mailing Address - Country:US
Mailing Address - Phone:256-479-8718
Mailing Address - Fax:
Practice Address - Street 1:1802 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1932
Practice Address - Country:US
Practice Address - Phone:208-814-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALS13130390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1311890OtherNABP