Healthcare Provider Details

I. General information

NPI: 1427553924
Provider Name (Legal Business Name): AUDREY GAIL MERRILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 N 16TH ST
PHOENIX AZ
85016-2903
US

IV. Provider business mailing address

5601 N 16TH ST
PHOENIX AZ
85016-2903
US

V. Phone/Fax

Practice location:
  • Phone: 602-664-7927
  • Fax: 602-664-7975
Mailing address:
  • Phone: 602-664-7927
  • Fax: 602-664-7975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3431
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number3431
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: