Healthcare Provider Details

I. General information

NPI: 1356659072
Provider Name (Legal Business Name): LISA A EHLENBERGER-WITT MA, CAGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 S 7TH ST
PHOENIX AZ
85042-4211
US

IV. Provider business mailing address

6218 S 7TH ST
PHOENIX AZ
85042-4211
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-4866
  • Fax: 602-304-3132
Mailing address:
  • Phone: 602-243-4866
  • Fax: 602-304-3132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3258273
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: