Healthcare Provider Details

I. General information

NPI: 1740717024
Provider Name (Legal Business Name): MARIA AVENA MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 S 1ST AVE
PHOENIX AZ
85003-2605
US

IV. Provider business mailing address

1209 S 1ST AVE
PHOENIX AZ
85003-2605
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-6796
  • Fax: 602-254-7121
Mailing address:
  • Phone: 602-258-6797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number16461
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: