Healthcare Provider Details

I. General information

NPI: 1992799068
Provider Name (Legal Business Name): KATHY RADINA M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SUNDIAL CIRCLE #2
CAREFREE AZ
85377
US

IV. Provider business mailing address

PO BOX 4410
CAVE CREEK AZ
85327-4410
US

V. Phone/Fax

Practice location:
  • Phone: 480-488-6096
  • Fax:
Mailing address:
  • Phone: 480-488-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-1404
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: