Healthcare Provider Details

I. General information

NPI: 1962653824
Provider Name (Legal Business Name): VIRGINIA MARY LAWRENCE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GINGER LAWRENCE PH.D.

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11589 E DEER TRAIL LN
DEWEY AZ
86327-5736
US

IV. Provider business mailing address

11589 E DEER TRAIL LN
DEWEY AZ
86327-5736
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-2897
  • Fax: 928-772-2897
Mailing address:
  • Phone: 928-772-2897
  • Fax: 928-772-2897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3779
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: