=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043009517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN ANTHONY WRIGHT E.DS., PHD.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2025
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7046 W CANDLEWOOD WAY
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85132-6972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-754-5362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7046 W CANDLEWOOD WAY
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85132-6972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-754-5362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 4506584
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------