=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265245062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLETTE ANN DACEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2025
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 S 3RD AVE
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-2264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-772-5195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3032 N 201ST GLN
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85396-8442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-357-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------