Healthcare Provider Details

I. General information

NPI: 1124760897
Provider Name (Legal Business Name): MING AN LIU MC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA LIU MC, LAC

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E BASELINE RD STE F8
TEMPE AZ
85283-1519
US

IV. Provider business mailing address

510 S EXTENSION RD APT 2086
MESA AZ
85210-2224
US

V. Phone/Fax

Practice location:
  • Phone: 520-610-9736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-17715
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: