Healthcare Provider Details

I. General information

NPI: 1851710222
Provider Name (Legal Business Name): NEIL TRAVIS HETZEL MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18843 W LAUREL LN
SURPRISE AZ
85388-3258
US

IV. Provider business mailing address

18843 W LAUREL LN
SURPRISE AZ
85388-3258
US

V. Phone/Fax

Practice location:
  • Phone: 623-466-3482
  • Fax:
Mailing address:
  • Phone: 623-466-3482
  • Fax: 480-963-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-17620
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-14358
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: