1972261824 NPI number — KETAMINE PSYCHOLYTIC THERAPY LLC

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 1972261824 NPI number — KETAMINE PSYCHOLYTIC THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETAMINE PSYCHOLYTIC THERAPY LLC
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:
1972261824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 CASTLE ROCK ROAD STE 2A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEDONA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-730-9097
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 CASTLE ROCK ROAD STE 2A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-814-5269
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CUNNINGHAM
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
610-730-9097

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com