Healthcare Provider Details

I. General information

NPI: 1801016878
Provider Name (Legal Business Name): PROFESSIONAL PSYCHOLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 E CAMELBACK RD SUITE H230
PHOENIX AZ
85018-2745
US

IV. Provider business mailing address

4222 E CAMELBACK ROAD SUITE H230
PHOENIX AZ
85018-2787
US

V. Phone/Fax

Practice location:
  • Phone: 602-852-0911
  • Fax: 602-852-0632
Mailing address:
  • Phone: 602-852-0911
  • Fax: 602-852-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberBH934
License Number StateAZ

VIII. Authorized Official

Name: DR. PHILLIP D LETT
Title or Position: ADMINISTRATOR/PRESIDENT
Credential: PHD
Phone: 602-852-0911