Healthcare Provider Details

I. General information

NPI: 1487262606
Provider Name (Legal Business Name): ANNA LEE THEBEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17490 N 93RD ST
SCOTTSDALE AZ
85255-6323
US

IV. Provider business mailing address

10888 N 70TH ST APT 171
SCOTTSDALE AZ
85254-6114
US

V. Phone/Fax

Practice location:
  • Phone: 480-588-5386
  • Fax:
Mailing address:
  • Phone: 520-409-0374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-006169
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTA-006169
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: