Provider Demographics
NPI:1043462542
Name:HERON, PAUL J (LCSW)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:HERON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5676 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2138
Mailing Address - Country:US
Mailing Address - Phone:718-796-5300
Mailing Address - Fax:718-548-1161
Practice Address - Street 1:5676 RIVERDALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-2138
Practice Address - Country:US
Practice Address - Phone:718-796-5300
Practice Address - Fax:718-548-1161
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078421-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400067140Medicare PIN