Healthcare Provider Details

I. General information

NPI: 1750362604
Provider Name (Legal Business Name): STUART B FENSTERHEIM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 E SOUTHERN AVE SUITE 201
MESA AZ
85204-5241
US

IV. Provider business mailing address

1855 E SOUTHERN AVE SUITE 201
MESA AZ
85204-5241
US

V. Phone/Fax

Practice location:
  • Phone: 480-560-1981
  • Fax: 480-813-4721
Mailing address:
  • Phone: 480-560-1981
  • Fax: 480-813-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW1705
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: