Healthcare Provider Details

I. General information

NPI: 1780013797
Provider Name (Legal Business Name): PAT MEDFORD M.A./L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21139 W CARAVAGGIO LN
WITTMANN AZ
85361-8685
US

IV. Provider business mailing address

15270 W BROOKSIDE LN
SURPRISE AZ
85374-2450
US

V. Phone/Fax

Practice location:
  • Phone: 623-210-2561
  • Fax:
Mailing address:
  • Phone: 623-210-2561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-10557
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: