Healthcare Provider Details

I. General information

NPI: 1669991303
Provider Name (Legal Business Name): MELISSA KINWORTHY MS, LASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 E SOUTHERN AVE
TEMPE AZ
85282-7503
US

IV. Provider business mailing address

2115 E SOUTHERN AVE
TEMPE AZ
85282-7503
US

V. Phone/Fax

Practice location:
  • Phone: 480-831-9533
  • Fax:
Mailing address:
  • Phone: 480-831-9533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13241
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: