Provider Demographics
NPI:1598343188
Name:MERRELL, PHIL (MED LAC)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:MERRELL
Suffix:
Gender:M
Credentials:MED LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 N SHARON DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8240
Mailing Address - Country:US
Mailing Address - Phone:907-500-3455
Mailing Address - Fax:
Practice Address - Street 1:510 E MOELLER ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2612
Practice Address - Country:US
Practice Address - Phone:928-420-8300
Practice Address - Fax:928-350-6404
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19524101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor