Provider Demographics
NPI:1912145657
Name:FARRELL, ROBERT LESLIE (MED,NCC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LESLIE
Last Name:FARRELL
Suffix:
Gender:M
Credentials:MED,NCC
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 1079
Mailing Address - Street 2:1333 W. PICACHO DR.
Mailing Address - City:ASH FORK
Mailing Address - State:AZ
Mailing Address - Zip Code:86320-1079
Mailing Address - Country:US
Mailing Address - Phone:928-310-9231
Mailing Address - Fax:
Practice Address - Street 1:601 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-1905
Practice Address - Country:US
Practice Address - Phone:928-635-4428
Practice Address - Fax:928-635-1213
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor