Healthcare Provider Details

I. General information

NPI: 1518494418
Provider Name (Legal Business Name): AFRICA LATRICE OGDEN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N CENTRAL AVE STE 101
PHOENIX AZ
85004-1300
US

IV. Provider business mailing address

219 W HARVARD AVE
GILBERT AZ
85233-3304
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-9891
  • Fax:
Mailing address:
  • Phone: 480-276-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-15920
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-15920
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: