1821003419 NPI number — PROFESSIONAL PSYCHOLOGY ASSOCIATES PC

Table of content: (NPI 1821003419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821003419 NPI number — PROFESSIONAL PSYCHOLOGY ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PSYCHOLOGY ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTER FOR LIFESTYLE CHANGE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821003419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 E CAMELBACK RD
Provider Second Line Business Mailing Address:
SUITE H230
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85018-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-852-0911
Provider Business Mailing Address Fax Number:
602-852-0632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4222 E CAMELBACK RD
Provider Second Line Business Practice Location Address:
SUITE H230
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85018-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-852-0911
Provider Business Practice Location Address Fax Number:
602-852-0632
Provider Enumeration Date:
07/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LETT
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
602-852-0911

Provider Taxonomy Codes

  • Taxonomy code: 103TR0400X , with the licence number:  BH934 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)