Healthcare Provider Details

I. General information

NPI: 1801097167
Provider Name (Legal Business Name): ANDREW KENT RATHBUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 W GREENBRIAR DR
GLENDALE AZ
85308-3724
US

IV. Provider business mailing address

20402 N 15TH AVE
PHOENIX AZ
85027-3636
US

V. Phone/Fax

Practice location:
  • Phone: 602-467-5500
  • Fax: 602-467-5580
Mailing address:
  • Phone: 623-445-4952
  • Fax: 623-445-5086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3804461
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: