Healthcare Provider Details

I. General information

NPI: 1053577023
Provider Name (Legal Business Name): THE CHILDRENS CENTER FOR NEURODEVELOPMENTAL STUDIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 W GLENN DR
GLENDALE AZ
85301-2628
US

IV. Provider business mailing address

5430 W GLENN DR
GLENDALE AZ
85301-2628
US

V. Phone/Fax

Practice location:
  • Phone: 623-915-0345
  • Fax: 623-937-5425
Mailing address:
  • Phone: 623-915-0345
  • Fax: 623-937-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number4184
License Number StateAZ

VIII. Authorized Official

Name: MARTINA MUSSER
Title or Position: BUSINESS SERVICES
Credential:
Phone: 623-915-0345