Provider Demographics
NPI:1093724379
Name:HEERBOTH, JOEL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:R
Last Name:HEERBOTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 E RIVER RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5842
Mailing Address - Country:US
Mailing Address - Phone:520-293-1673
Mailing Address - Fax:520-615-0355
Practice Address - Street 1:268 E RIVER RD
Practice Address - Street 2:SUITE 160
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5842
Practice Address - Country:US
Practice Address - Phone:520-293-1673
Practice Address - Fax:520-615-0355
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1106103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR11820Medicare UPIN
AZZPHD1106Medicare ID - Type UnspecifiedMEDICARE ID NUMBER