Healthcare Provider Details

I. General information

NPI: 1659997575
Provider Name (Legal Business Name): CA LITRA LYNNETTE GOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 W ECHO LN
PHOENIX AZ
85021-4856
US

IV. Provider business mailing address

6109 N 12TH ST UNIT 8
PHOENIX AZ
85014-1716
US

V. Phone/Fax

Practice location:
  • Phone: 602-877-6686
  • Fax:
Mailing address:
  • Phone: 602-877-6686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: