Healthcare Provider Details

I. General information

NPI: 1972163202
Provider Name (Legal Business Name): EDITH TWITCHELL LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 410
GLENDALE AZ
85308-8732
US

IV. Provider business mailing address

23592 W WAYLAND DR
BUCKEYE AZ
85326-7245
US

V. Phone/Fax

Practice location:
  • Phone: 623-800-7980
  • Fax: 623-242-1107
Mailing address:
  • Phone: 480-432-6394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number15122
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: