Healthcare Provider Details

I. General information

NPI: 1184612442
Provider Name (Legal Business Name): DAWN DYAN ABBOTT MA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 WESTERN AVE
KINGMAN AZ
86409-3011
US

IV. Provider business mailing address

1743 SYCAMORE AVE MOHAVE MENTAL HEALTH CLINIC INC
KINGMAN AZ
86409-0927
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8111
  • Fax: 928-757-3256
Mailing address:
  • Phone: 928-757-8111
  • Fax: 928-757-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC1355
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: