Provider Demographics
NPI:1871170837
Name:HERON, CAROLYN P (LCDC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:P
Last Name:HERON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 LAGO TRL
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-2958
Mailing Address - Country:US
Mailing Address - Phone:667-240-3944
Mailing Address - Fax:
Practice Address - Street 1:2307 LAGO TRL
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-2958
Practice Address - Country:US
Practice Address - Phone:667-240-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12533101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)