Healthcare Provider Details

I. General information

NPI: 1588061634
Provider Name (Legal Business Name): NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 W SR 89A ST 105
SEDONA AZ
86336-5468
US

IV. Provider business mailing address

989 S MAIN ST BOX 447
COTTONWOOD AZ
86326-4601
US

V. Phone/Fax

Practice location:
  • Phone: 928-821-3403
  • Fax: 928-282-1852
Mailing address:
  • Phone: 928-821-3403
  • Fax: 928-282-1852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36928
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number36928
License Number StateAZ

VIII. Authorized Official

Name: MS. LINDA COLLEEN TOLLESON
Title or Position: CO-OWNER
Credential:
Phone: 928-821-5173