Basic Information
| Provider Information | |||||||||
| NPI: | 1831685320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALING SERVICE AGENCY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HSA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17505 N 79TH AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238505400 | ||||||||
| FaxNumber: | 6233217850 | ||||||||
| Practice Location | |||||||||
| Address1: | 17505 N 79TH AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238505400 | ||||||||
| FaxNumber: | 6233217850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2018 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARSHALL | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6238505400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | LCSW-17245 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.