Healthcare Provider Details

I. General information

NPI: 1669944914
Provider Name (Legal Business Name): NOEL ALTAHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 WEST BEARGRASS DRIVE
FORT APACHE AZ
85926-0803
US

IV. Provider business mailing address

PO BOX 803
FORT APACHE AZ
85926-0803
US

V. Phone/Fax

Practice location:
  • Phone: 480-519-6392
  • Fax:
Mailing address:
  • Phone: 480-519-6392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-20757
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104726-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: