Provider Demographics
NPI:1730169913
Name:O'HEARN, MICHAEL K (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:K
Last Name:O'HEARN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 PLAZA DEL SUR DR APT 147
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6046
Mailing Address - Country:US
Mailing Address - Phone:505-955-9454
Mailing Address - Fax:505-216-9067
Practice Address - Street 1:1862 PLAZA DEL SUR DR APT 147
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6046
Practice Address - Country:US
Practice Address - Phone:513-766-2496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1.0007335101YM0800X
NMSWB-2023-05251041C0700X
CA981931041C0700X
OHI.0007335-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH250935UBSOtherUNITED BEHAVIORAL HEALTH
SW22612Medicare PIN
OH250935UBSOtherUNITED BEHAVIORAL HEALTH