Healthcare Provider Details

I. General information

NPI: 1669762183
Provider Name (Legal Business Name): MAYRA KMETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8147 N CEDAR ST
WILLIAMS AZ
86046-9642
US

IV. Provider business mailing address

700 QUARTER HORSE RD
WILLIAMS AZ
86046-9519
US

V. Phone/Fax

Practice location:
  • Phone: 928-607-0220
  • Fax:
Mailing address:
  • Phone: 928-607-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number2638357
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number2638357
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: