Healthcare Provider Details

I. General information

NPI: 1700192473
Provider Name (Legal Business Name): BRIAN SEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13801 E BENSON HWY
VAIL AZ
85641-9074
US

IV. Provider business mailing address

PO BOX 800 13801 E. BENSON HIGHWAY
VAIL AZ
85641-0800
US

V. Phone/Fax

Practice location:
  • Phone: 520-879-2052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4256236
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: