Healthcare Provider Details

I. General information

NPI: 1154548139
Provider Name (Legal Business Name): SANDRA SUE MCCONNELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 S GRANITE ST
PRESCOTT AZ
86303-4710
US

IV. Provider business mailing address

146 S GRANITE ST
PRESCOTT AZ
86303-4710
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-5400
  • Fax:
Mailing address:
  • Phone: 928-445-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3786615
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: