Healthcare Provider Details

I. General information

NPI: 1750150942
Provider Name (Legal Business Name): SOUTHWEST AUTISM RESEARCH AND RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 N 16TH ST
PHOENIX AZ
85006-1823
US

IV. Provider business mailing address

2225 N 16TH ST
PHOENIX AZ
85006-1823
US

V. Phone/Fax

Practice location:
  • Phone: 602-340-8717
  • Fax: 602-340-8720
Mailing address:
  • Phone: 602-340-8717
  • Fax: 602-340-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN SHAW
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 602-218-8211