Healthcare Provider Details

I. General information

NPI: 1841686078
Provider Name (Legal Business Name): SPECTRUM VILLAGE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 W PEORIA AVE STE. 133
PHOENIX AZ
85029-3900
US

IV. Provider business mailing address

4150 W PEORIA AVE STE. 133
PHOENIX AZ
85029-3900
US

V. Phone/Fax

Practice location:
  • Phone: 602-910-0526
  • Fax: 602-346-0117
Mailing address:
  • Phone: 602-910-0526
  • Fax: 602-346-0117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4484
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number127
License Number StateAZ

VIII. Authorized Official

Name: DR. LORI KIM LICHTE-BRILL
Title or Position: CHIEF CLINICAL OFFICER
Credential: PSY.D.
Phone: 602-910-0526