Provider Demographics
NPI:1346858883
Name:ROMERO, HEATHER (LISAC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ROMERO
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3019 W CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W CAMELBACK RD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2564
Practice Address - Country:US
Practice Address - Phone:602-230-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
AZ15163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)