Healthcare Provider Details

I. General information

NPI: 1962196253
Provider Name (Legal Business Name): RANI HANTLA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 E BANNER GATEWAY DR
GILBERT AZ
85234-2165
US

IV. Provider business mailing address

1640 W ORCHID LN
CHANDLER AZ
85224-4081
US

V. Phone/Fax

Practice location:
  • Phone: 480-634-3454
  • Fax:
Mailing address:
  • Phone: 480-634-3454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY-005634
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: