Provider Demographics
NPI:1427553924
Name:MERRILL, AUDREY GAIL
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:GAIL
Last Name:MERRILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2903
Mailing Address - Country:US
Mailing Address - Phone:602-664-7927
Mailing Address - Fax:602-664-7975
Practice Address - Street 1:5601 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2903
Practice Address - Country:US
Practice Address - Phone:602-664-7927
Practice Address - Fax:602-664-7975
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34311041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool