Provider Demographics
NPI:1245305606
Name:CONYNGHAM, HEATHER ANN (PHD)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANN
Last Name:CONYNGHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 VIRGINIA ST NE
Mailing Address - Street 2:STE. A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4692
Mailing Address - Country:US
Mailing Address - Phone:505-291-6314
Mailing Address - Fax:505-275-0296
Practice Address - Street 1:2527 VIRGINIA ST NE
Practice Address - Street 2:STE. A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4692
Practice Address - Country:US
Practice Address - Phone:505-291-6314
Practice Address - Fax:505-275-0296
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0899103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75439875Medicaid