Healthcare Provider Details

I. General information

NPI: 1437234325
Provider Name (Legal Business Name): CAROL ANN GEGENHEIMER PH.D., LISAC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 N 67TH AVENUE SUITE 400
GLENDALE AZ
85308-3698
US

IV. Provider business mailing address

17100 N 67TH AVENUE SUITE 400
GLENDALE AZ
85308-3698
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3323
  • Fax: 602-938-1626
Mailing address:
  • Phone: 602-938-3323
  • Fax: 602-938-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10198
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-10101
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: