1831596915 NPI number — AZ CHILD AND FAMILY PSYCHOLOGICAL SERVICES, PLLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831596915 NPI number — AZ CHILD AND FAMILY PSYCHOLOGICAL SERVICES, PLLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZ CHILD AND FAMILY PSYCHOLOGICAL SERVICES, PLLC.
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:
Provider Other Organization Name Type Code:
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:
1831596915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3048 E. BASELINE ROAD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-457-8543
Provider Business Mailing Address Fax Number:
602-293-3271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3048 E BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-7286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-457-8543
Provider Business Practice Location Address Fax Number:
602-293-3271
Provider Enumeration Date:
12/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CAJOLET-ECKHARDT
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
262-515-2445

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43702600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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