Healthcare Provider Details

I. General information

NPI: 1962338863
Provider Name (Legal Business Name): TAMALA HARVEY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SOUTHERN AVE STE 1051
MESA AZ
85206-6205
US

IV. Provider business mailing address

PO BOX 3497
SAINT JOHNS AZ
85936-3497
US

V. Phone/Fax

Practice location:
  • Phone: 480-258-9653
  • Fax:
Mailing address:
  • Phone: 480-258-9653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-24051
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: