Healthcare Provider Details

I. General information

NPI: 1043930662
Provider Name (Legal Business Name): ID SUBSTRATE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 N 32ND ST STE 100A
PHOENIX AZ
85018-3360
US

IV. Provider business mailing address

PO BOX 10044
PHOENIX AZ
85064-0044
US

V. Phone/Fax

Practice location:
  • Phone: 602-200-8690
  • Fax: 602-264-8107
Mailing address:
  • Phone: 602-405-4622
  • Fax: 602-264-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. DAWN M CRAIG
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-561-7806