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General NPI Number Information
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NPI Number | 1992227235
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Entity Type | Organization
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Legal Business Name | EAST VALLEY TRAUMA COUNSELING LLC
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Dates
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Enumeration Date | 07/07/2017
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 1166 E WARNER RD STE 206
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City | GILBERT
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State | AZ
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Zip | 85296-3066
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Country | US
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Telephone | 480-462-7728
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Fax | 480-452-1530
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Provider Business Mailing Address
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Address Line | 3641 W LAREDO ST
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City | CHANDLER
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State | AZ
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Zip | 85226-2233
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Country | US
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Telephone | 480-776-4155
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | STACY DELUCA
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Credential |
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Telephone | 602-741-3077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 16034
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License Number State | AZ
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