=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770520116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM PSYCHOLOGY SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 02/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16108 E EMERALD DR UNIT 204
-----------------------------------------------------
City | FOUNTAIN HILLS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85268-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-978-8294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16108 E EMERALD DR UNIT 204
-----------------------------------------------------
City | FOUNTAIN HILLS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85268-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-978-8294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | ANTHONY V SANTORO
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 516-978-8294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 013294
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------