=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568595932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN CARLOS U. S. D. # 20
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SAN CARLOS AVE
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 28-475-2315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SAN CARLOS AVE.
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SCHOOL COUNSELOR
-----------------------------------------------------
Name | MRS. DEIDRE ANN DERHAMMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-475-2315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------