Healthcare Provider Details

I. General information

NPI: 1184553042
Provider Name (Legal Business Name): MR. THEMBANI TIMOTHY HLAZO-THREADGILL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W MARYLAND AVE
PHOENIX AZ
85013-1227
US

IV. Provider business mailing address

6040 W CROCUS DR
GLENDALE AZ
85306-4137
US

V. Phone/Fax

Practice location:
  • Phone: 602-265-7484
  • Fax:
Mailing address:
  • Phone: 623-640-3105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-24760
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: