Healthcare Provider Details

I. General information

NPI: 1679719306
Provider Name (Legal Business Name): MARY ANN B. THIRAKUL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARY ANN BELTRAN THIRAKUL
Title or Position: OWNER/PSYCHOLOGIST
Credential: PSY.D.
Phone: 480-775-5154