Healthcare Provider Details

I. General information

NPI: 1851725212
Provider Name (Legal Business Name): MINDY BESS LACASSE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 N 24TH ST
PHOENIX AZ
85016-6512
US

IV. Provider business mailing address

3825 N 24TH ST
PHOENIX AZ
85016-6512
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-7997
  • Fax: 602-954-0980
Mailing address:
  • Phone: 602-955-7997
  • Fax: 602-954-0980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-12717
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: