Healthcare Provider Details

I. General information

NPI: 1891260113
Provider Name (Legal Business Name): MARA PSYCHOTHERAPY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2018
Last Update Date: 10/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7609 N 34TH AVE
PHOENIX AZ
85051-7417
US

IV. Provider business mailing address

7609 N 34TH AVE
PHOENIX AZ
85051-7417
US

V. Phone/Fax

Practice location:
  • Phone: 602-334-9904
  • Fax:
Mailing address:
  • Phone: 602-334-9904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN DRZEWIECKI
Title or Position: CEO
Credential: PSYD, LP
Phone: 602-334-9904