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General NPI Number Information
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NPI Number | 1174217210
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Entity Type | Organization
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Legal Business Name | E&G OUTPATIENT CENTER LLC
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Dates
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Enumeration Date | 06/02/2023
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Last Update Date | 06/02/2023
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Provider Practice Location Address
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Address Line | 3802 N 53RD AVE STE 280
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City | PHOENIX
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State | AZ
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Zip | 85031-3021
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Country | US
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Telephone | 614-818-8442
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Fax |
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Provider Business Mailing Address
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Address Line | 5224 W SIESTA WAY
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City | LAVEEN
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State | AZ
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Zip | 85339-7178
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Country | US
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Telephone | 614-818-8442
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | GISELE KAYITESI
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Credential |
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Telephone | 614-818-8442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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