Healthcare Provider Details

I. General information

NPI: 1396385514
Provider Name (Legal Business Name): KAITLIN LARISSA ABRAVAYA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 E INVERNESS AVE STE 109
MESA AZ
85206-3848
US

IV. Provider business mailing address

11024 E DIAMOND AVE
MESA AZ
85208-7647
US

V. Phone/Fax

Practice location:
  • Phone: 480-645-1610
  • Fax:
Mailing address:
  • Phone: 480-645-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC18255
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: