Healthcare Provider Details

I. General information

NPI: 1336547595
Provider Name (Legal Business Name): LITCHFIELD SCHOOL DISTRICT #79
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 E SAGEBRUSH ST
LITCHFIELD PARK AZ
85340-4934
US

IV. Provider business mailing address

272 E SAGEBRUSH ST
LITCHFIELD PARK AZ
85340-4934
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-6000
  • Fax:
Mailing address:
  • Phone: 623-535-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number2590
License Number StateAZ

VIII. Authorized Official

Name: HEATHER MARIE ROYSTER
Title or Position: OCCUPATIONAL THERAPIST
Credential: OT/L
Phone: 623-238-3089