=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043635758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ FAMILY THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2014
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 N. SWAN RD SUITE 244
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-4053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-327-5522
-----------------------------------------------------
Fax | 520-327-5525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 N. SWAN RD SUITE 244
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-4053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-327-5522
-----------------------------------------------------
Fax | 520-327-5525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH R LEINWEBER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 520-327-5522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW2595
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------