Healthcare Provider Details

I. General information

NPI: 1497880116
Provider Name (Legal Business Name): KELLY KRIETSCH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 SOUTHWEST DR
SEDONA AZ
86336-3797
US

IV. Provider business mailing address

1016 W UNIVERSITY AVE SUITE #202
FLAGSTAFF AZ
86001-2994
US

V. Phone/Fax

Practice location:
  • Phone: 928-203-4844
  • Fax: 928-203-4497
Mailing address:
  • Phone: 928-779-4286
  • Fax: 928-774-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: