Healthcare Provider Details

I. General information

NPI: 1922915495
Provider Name (Legal Business Name): KIRSTEN YAKSICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 W MOUNTAIN VIEW BLVD STE 240
SURPRISE AZ
85374-2702
US

IV. Provider business mailing address

13937 N 147TH DR
SURPRISE AZ
85379-7441
US

V. Phone/Fax

Practice location:
  • Phone: 623-363-8483
  • Fax:
Mailing address:
  • Phone: 623-363-8483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23314
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: