Healthcare Provider Details

I. General information

NPI: 1801255633
Provider Name (Legal Business Name): GLENDALE THERAPY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 N 67TH AVE STE 400
GLENDALE AZ
85308-3698
US

IV. Provider business mailing address

17100 N 67TH AVE STE 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 TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROL GEGENHEIMER
Title or Position: MEMBER
Credential: PHD
Phone: 602-938-3323