Healthcare Provider Details

I. General information

NPI: 1104554237
Provider Name (Legal Business Name): EAST VALLEY FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD STE 132
QUEEN CREEK AZ
85142-5995
US

IV. Provider business mailing address

21321 E OCOTILLO RD STE 132
QUEEN CREEK AZ
85142-5995
US

V. Phone/Fax

Practice location:
  • Phone: 602-759-0512
  • Fax: 602-584-7290
Mailing address:
  • Phone: 602-759-0512
  • Fax: 602-584-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN HARROP
Title or Position: OWNER
Credential: LMFT
Phone: 602-759-0512