Healthcare Provider Details

I. General information

NPI: 1265590418
Provider Name (Legal Business Name): MARYANN BELTRAN THIRAKUL PSYD.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 S. DOBSON RD. SUITE 200
MESA AZ
85202
US

IV. Provider business mailing address

1830 S ALMA SCHOOL RD STE 104
MESA AZ
85210-3086
US

V. Phone/Fax

Practice location:
  • Phone: 480-775-5154
  • Fax: 480-744-2726
Mailing address:
  • Phone: 480-344-7088
  • Fax: 480-744-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3783
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3783
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3783
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: