=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720388200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENYA R MCCRAY LISAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 02/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 S 1ST AVE STE 3
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-2260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-9490
-----------------------------------------------------
Fax | 480-288-5339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3160
-----------------------------------------------------
City | APACHE JUNCTION
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85117-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-344-9490
-----------------------------------------------------
Fax | 480-288-5339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LISAC-10480
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 10480
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------