Healthcare Provider Details

I. General information

NPI: 1407479645
Provider Name (Legal Business Name): ELIZABETH ADAIR FREESE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19636 N 27TH AVE STE 106
PHOENIX AZ
85027-4014
US

IV. Provider business mailing address

7501 N 18TH AVE
PHOENIX AZ
85021-7909
US

V. Phone/Fax

Practice location:
  • Phone: 480-712-4600
  • Fax:
Mailing address:
  • Phone: 480-532-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-16948
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: