Healthcare Provider Details

I. General information

NPI: 1902202567
Provider Name (Legal Business Name): KATHY SUE DUTRIDGE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 W VAN BUREN ST
PHOENIX AZ
85007-2414
US

IV. Provider business mailing address

202 E EARLL DR SUITE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-252-7330
  • Fax: 602-252-4797
Mailing address:
  • Phone: 602-599-5404
  • Fax: 602-599-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-16803
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: