Healthcare Provider Details

I. General information

NPI: 1275698193
Provider Name (Legal Business Name): KATHY ELDRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8351 W SAN MIGUEL AVE
GLENDALE AZ
85305-2910
US

IV. Provider business mailing address

8351 W SAN MIGUEL AVE
GLENDALE AZ
85305-2910
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-0652
  • Fax:
Mailing address:
  • Phone: 623-772-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number9246
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: