Healthcare Provider Details

I. General information

NPI: 1528565793
Provider Name (Legal Business Name): KELSI ANNE RATHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 N 79TH AVE STE C133
GLENDALE AZ
85308-8471
US

IV. Provider business mailing address

18301 N 79TH AVE STE C133
GLENDALE AZ
85308-8471
US

V. Phone/Fax

Practice location:
  • Phone: 623-748-3337
  • Fax: 623-234-3751
Mailing address:
  • Phone: 623-748-3337
  • Fax: 623-234-3751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-17140
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: