Healthcare Provider Details

I. General information

NPI: 1508559071
Provider Name (Legal Business Name): RODNEY SCOTT SUDCC AII059340121
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14804 N CAVE CREEK RD
PHOENIX AZ
85032-4945
US

IV. Provider business mailing address

4520 E BASELINE RD APT 2027
PHOENIX AZ
85042-7432
US

V. Phone/Fax

Practice location:
  • Phone: 602-667-3970
  • Fax:
Mailing address:
  • Phone: 602-667-3970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII059340121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: