MEDICARE: MAURA RUTH ANNALYSSE TAPIA LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LAC-19829	AZ

General Provider Information

NPI Number	:	1124782958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAURA RUTH ANNALYSSE TAPIA LAC

Provider Business Mailing Address
First Line	:	101 N 1ST AVE STE 2310
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85003-1902
Country	:	US
Telephone Number	:	312-578-9990
Fax Number	:

Provider Business Practice Location Address
First Line	:	1854 E INTREPID AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6817
Country	:	US
Telephone Number	:	480-600-0548
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2021
Last Update Date	:	10/27/2021

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