Healthcare Provider Details

I. General information

NPI: 1104747542
Provider Name (Legal Business Name): LINDA DE ANDA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 E VIRGINIA AVE
PHOENIX AZ
85006-1324
US

IV. Provider business mailing address

5401 E THOMAS RD UNIT 1036
PHOENIX AZ
85018-8134
US

V. Phone/Fax

Practice location:
  • Phone: 602-381-6120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: