MEDICARE: TAHONNA LATREISE SURRELL MS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1508478082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAHONNA LATREISE SURRELL MS

Provider Business Mailing Address
First Line	:	3236 E CHANDLER BLVD UNIT 1034
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7281
Country	:	US
Telephone Number	:	520-280-6272
Fax Number	:

Provider Business Practice Location Address
First Line	:	3236 E CHANDLER BLVD UNIT 1034
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7281
Country	:	US
Telephone Number	:	520-280-6272
Fax Number	:

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

Provider Enumeration Date	:	08/17/2020
Last Update Date	:	08/17/2020

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