Healthcare Provider Details

I. General information

NPI: 1629282686
Provider Name (Legal Business Name): DONNA JEAN SALAZAR M. ED., LBA, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N OLIVE AVE
CASA GRANDE AZ
85122-4034
US

IV. Provider business mailing address

PO BOX 562
FLORENCE AZ
85132-3010
US

V. Phone/Fax

Practice location:
  • Phone: 520-840-0697
  • Fax: 520-635-5331
Mailing address:
  • Phone: 520-840-0697
  • Fax: 520-635-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-11747
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-000773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: