Provider Demographics
NPI:1053792622
Name:IRVIN, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-1222
Mailing Address - Country:US
Mailing Address - Phone:706-325-3288
Mailing Address - Fax:
Practice Address - Street 1:4624 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-1222
Practice Address - Country:US
Practice Address - Phone:706-325-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator