=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851969117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLIN JOSEPH PSYCHOLOGIST PHD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2021
-----------------------------------------------------
Last Update Date | 07/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1666 W PINE CONE WAY
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-6123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-499-8405
-----------------------------------------------------
Fax | 928-227-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1666 W PINE CONE WAY
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-6123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-499-8405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LISA LOU SHANNON-JOSEPH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-499-8405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------