Healthcare Provider Details

I. General information

NPI: 1790373272
Provider Name (Legal Business Name): JOHN KNAPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2021
Last Update Date: 01/09/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 W CAMPBELL AVE STE 204
PHOENIX AZ
85031-1719
US

IV. Provider business mailing address

5251 W CAMPBELL AVE STE 204
PHOENIX AZ
85031-1719
US

V. Phone/Fax

Practice location:
  • Phone: 623-293-2232
  • Fax:
Mailing address:
  • Phone: 623-293-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLASAC-15173
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: