Healthcare Provider Details

I. General information

NPI: 1164044897
Provider Name (Legal Business Name): SUN RIDGE PSYCHOTHERAPY LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2948 E 8TH ST
TUCSON AZ
85716-5248
US

IV. Provider business mailing address

11001 E ROGER RD
TUCSON AZ
85749-8563
US

V. Phone/Fax

Practice location:
  • Phone: 520-261-9556
  • Fax:
Mailing address:
  • Phone: 707-495-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA JANE JONES
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 520-261-9556