Healthcare Provider Details

I. General information

NPI: 1356958185
Provider Name (Legal Business Name): TUJUAN NOVEL NETTERS LAMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N 16TH ST STE 102
PHOENIX AZ
85020-5266
US

IV. Provider business mailing address

229 E HARVARD DR
TEMPE AZ
85283-1844
US

V. Phone/Fax

Practice location:
  • Phone: 513-850-2782
  • Fax:
Mailing address:
  • Phone: 623-451-4961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAMFT-10565
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAMFT-10565
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: