Healthcare Provider Details

I. General information

NPI: 1629603642
Provider Name (Legal Business Name): HEATHER REBECCA KOUTSOGIANNIS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WILLIAMS FIELD RD STE 200
GILBERT AZ
85295-0764
US

IV. Provider business mailing address

2200 E WILLIAMS FIELD RD STE 200
GILBERT AZ
85295-0764
US

V. Phone/Fax

Practice location:
  • Phone: 480-567-4918
  • Fax:
Mailing address:
  • Phone: 480-567-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005966
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: