Provider Demographics
NPI:1043896384
Name:HEFFERNAN, JOSH
Entity type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 POPLAR OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-7358
Mailing Address - Country:US
Mailing Address - Phone:404-993-4253
Mailing Address - Fax:
Practice Address - Street 1:644 TALLULAH TRL
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7625
Practice Address - Country:US
Practice Address - Phone:478-225-2179
Practice Address - Fax:478-352-0098
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21159950103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst