Healthcare Provider Details

I. General information

NPI: 1215546155
Provider Name (Legal Business Name): TRISHA DIANE OVERVAAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E BASELINE RD STE 5
PHOENIX AZ
85042-6536
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-441-5836
Mailing address:
  • Phone: 602-230-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number244751
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: