Provider Demographics
NPI:1689414476
Name:ILCONICH, HEATHER LISA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LISA
Last Name:ILCONICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MOUNTAINVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4729
Mailing Address - Country:US
Mailing Address - Phone:609-410-0865
Mailing Address - Fax:
Practice Address - Street 1:30 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2002
Practice Address - Country:US
Practice Address - Phone:917-647-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052753001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical