Provider Demographics
NPI:1689299232
Name:WALL, HEATHER (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236-0066
Mailing Address - Country:US
Mailing Address - Phone:480-818-6518
Mailing Address - Fax:
Practice Address - Street 1:11011 S 48TH ST STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1788
Practice Address - Country:US
Practice Address - Phone:480-818-6518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-172481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical