Healthcare Provider Details

I. General information

NPI: 1851157200
Provider Name (Legal Business Name): MATTHEW W. HENNINGER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 S POWER RD STE 103
MESA AZ
85212-3625
US

IV. Provider business mailing address

4135 S POWER RD STE 103
MESA AZ
85212-3625
US

V. Phone/Fax

Practice location:
  • Phone: 480-397-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: