Healthcare Provider Details

I. General information

NPI: 1881863579
Provider Name (Legal Business Name): MRS. TANISHA LAWRENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8705 W MORTEN AVE
GLENDALE AZ
85305-3944
US

IV. Provider business mailing address

8030 W OREGON AVE
GLENDALE AZ
85303-5547
US

V. Phone/Fax

Practice location:
  • Phone: 623-210-5169
  • Fax: 602-455-4624
Mailing address:
  • Phone: 623-210-5169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number571686
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number571686
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: