Healthcare Provider Details

I. General information

NPI: 1467438929
Provider Name (Legal Business Name): MERRILL R. HESLOP L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20185 E OCOTILLO RD #105
QUEEN CREEK AZ
85242-8799
US

IV. Provider business mailing address

20185 E OCOTILLO RD #105
QUEEN CREEK AZ
85242-8799
US

V. Phone/Fax

Practice location:
  • Phone: 480-987-2700
  • Fax: 480-987-2703
Mailing address:
  • Phone: 480-987-2700
  • Fax: 480-987-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-2817
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: