Healthcare Provider Details

I. General information

NPI: 1104044163
Provider Name (Legal Business Name): LARRY DELANO DRAUGHON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S EL DORADO CIR
MESA AZ
85202-1044
US

IV. Provider business mailing address

1709 E KAEL ST
MESA AZ
85203-2161
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-5647
  • Fax:
Mailing address:
  • Phone: 480-968-2995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW-01181
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: