Healthcare Provider Details

I. General information

NPI: 1588828529
Provider Name (Legal Business Name): MS. JODY MARIE ATTAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N. CARLISLE AVE
SOMERTON AZ
85350-3200
US

IV. Provider business mailing address

1046 S APPALOOSA LN
YUMA AZ
85364-3362
US

V. Phone/Fax

Practice location:
  • Phone: 928-341-6040
  • Fax: 928-341-6099
Mailing address:
  • Phone: 928-782-6315
  • Fax: 928-341-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2362764
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: