Healthcare Provider Details

I. General information

NPI: 1215219977
Provider Name (Legal Business Name): SHERRY WELBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N PLAZA DR
APACHE JUNCTION AZ
85120-5501
US

IV. Provider business mailing address

PO BOX 1316
APACHE JUNCTION AZ
85117-4054
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0065
  • Fax: 480-671-4541
Mailing address:
  • Phone: 480-983-0065
  • Fax: 480-671-4541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-12011
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: