=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801271481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL & CONSULTATION SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2015
-----------------------------------------------------
Last Update Date | 07/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 S MILL AVE SUITE 210
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-402-9042
-----------------------------------------------------
Fax | 480-829-9237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 S MILL AVE SUITE 210
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-402-9042
-----------------------------------------------------
Fax | 480-829-9237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. GREGORY NEIL SHRADER
-----------------------------------------------------
Credential | PH.D,
-----------------------------------------------------
Telephone | 602-402-9042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3029
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------