Healthcare Provider Details

I. General information

NPI: 1649475211
Provider Name (Legal Business Name): MS. MARYROSE TRONGCO GANDEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAJO ROUTE 12 WINDOW ROCK UNIFIED SCHOOL DISTRICT
FORT DELIANCE AZ
86504
US

IV. Provider business mailing address

PO BOX 2814
FORT DEFIANCE AZ
86504
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-6768
  • Fax: 928-729-7630
Mailing address:
  • Phone: 928-729-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: