Healthcare Provider Details

I. General information

NPI: 1831759240
Provider Name (Legal Business Name): THE UNIVERSITY OF ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 N CHERRY AVE
TUCSON AZ
85721-0105
US

IV. Provider business mailing address

1335 N CHERRY AVE
TUCSON AZ
85721-0105
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-2982
  • Fax: 520-626-2525
Mailing address:
  • Phone: 520-626-2982
  • Fax: 520-626-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ANNA GASTELUM
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 520-626-2982