Healthcare Provider Details

I. General information

NPI: 1386793412
Provider Name (Legal Business Name): BRONWYN RENEE MARSHALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRONWYN LOVITT-PAES

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 S MCCLINTOCK DR STE 105
TEMPE AZ
85282
US

IV. Provider business mailing address

1400 E SOUTHERN AVE STE 735
TEMPE AZ
85282-5699
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax: 480-804-0083
Mailing address:
  • Phone: 480-804-0326
  • Fax: 480-804-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-11303
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLCSW-11303
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: