Provider Demographics
NPI:1831685320
Name:HEALING SERVICE AGENCY LLC
Entity type:Organization
Organization Name:HEALING SERVICE AGENCY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:623-850-5400
Mailing Address - Street 1:17505 N 79TH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8726
Mailing Address - Country:US
Mailing Address - Phone:623-850-5400
Mailing Address - Fax:623-321-7850
Practice Address - Street 1:17505 N 79TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8726
Practice Address - Country:US
Practice Address - Phone:623-850-5400
Practice Address - Fax:623-321-7850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-08
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-17245261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty