=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477120434
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMAL NABIL FAYAD LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2021
-----------------------------------------------------
Last Update Date | 06/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2131 E BROADWAY RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-529-1875
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2310 S COTTONWOOD DR
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-3031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-931-9950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC-19209
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------