Healthcare Provider Details

I. General information

NPI: 1104400548
Provider Name (Legal Business Name): DURINA TAH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 W SOUTHERN AVE
MESA AZ
85210-5008
US

IV. Provider business mailing address

777 W SOUTHERN AVE
MESA AZ
85210-5008
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-5262
  • Fax:
Mailing address:
  • Phone: 602-279-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW18085
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-18085
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: