MEDICARE: STRATUM MENTAL HEALTH OF ARIZONA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1124486469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRATUM MENTAL HEALTH OF ARIZONA INC

Provider Business Mailing Address
First Line	:	40335 WINCHESTER RD # E221
Second Line	:
City	:	TEMECULA
State	:	CA
Zip	:	92591-5500
Country	:	US
Telephone Number	:	855-578-7288
Fax Number	:	888-741-7967

Provider Business Practice Location Address
First Line	:	3104 E CAMELBACK RD
Second Line	:	#2031
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4502
Country	:	US
Telephone Number	:	855-578-7288
Fax Number	:	888-741-7967

Authorized Official
Title or Position	:	OWNER
Name	:	MALCOLM ORLANDO GREYSON
Credential	:
Telephone Number	:	855-578-7288

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	02/02/2016

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