Healthcare Provider Details

I. General information

NPI: 1912775503
Provider Name (Legal Business Name): VONDELERE T SCOTT BSW, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7024 N 77TH DR
GLENDALE AZ
85303-2455
US

IV. Provider business mailing address

7024 N 77TH DR
GLENDALE AZ
85303-2455
US

V. Phone/Fax

Practice location:
  • Phone: 602-815-0930
  • Fax:
Mailing address:
  • Phone: 602-815-0930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: