Healthcare Provider Details

I. General information

NPI: 1265844831
Provider Name (Legal Business Name): ROBERT BERIDHA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 02/19/2023
Certification Date: 02/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N BEAVER ST
FLAGSTAFF AZ
86001-3103
US

IV. Provider business mailing address

711 N BEAVER ST
FLAGSTAFF AZ
86001-3103
US

V. Phone/Fax

Practice location:
  • Phone: 928-380-6081
  • Fax:
Mailing address:
  • Phone: 541-301-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR4311
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-005043
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number005043
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number005043
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: