Healthcare Provider Details

I. General information

NPI: 1477095073
Provider Name (Legal Business Name): KANNER PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E MISSOURI AVE
PHOENIX AZ
85014-2362
US

IV. Provider business mailing address

PO BOX 39179 SUITE 200
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR71751
License Number StateAZ

VIII. Authorized Official

Name: MS. LINDA HAMELIN
Title or Position: CREDENTIALER
Credential:
Phone: 602-308-7817