Provider Demographics
NPI:1053421131
Name:MCCONNELL, HEATHER (MA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3630
Mailing Address - Country:US
Mailing Address - Phone:479-747-1587
Mailing Address - Fax:
Practice Address - Street 1:911 NW LOOP 281
Practice Address - Street 2:SUITE 302
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604
Practice Address - Country:US
Practice Address - Phone:903-759-2402
Practice Address - Fax:903-759-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19658101YP2500X
ARP1402017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177772401Medicaid