Healthcare Provider Details

I. General information

NPI: 1407770795
Provider Name (Legal Business Name): ELISSA ANN HEERMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 N 4TH ST #481
FLAGSTAFF AZ
86004
US

IV. Provider business mailing address

19082 N 85TH LN
PEORIA AZ
85382-8712
US

V. Phone/Fax

Practice location:
  • Phone: 928-226-1563
  • Fax:
Mailing address:
  • Phone: 307-752-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA17727
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: