MEDICARE: KRISONA HEUSTED

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	385HR2055X	Child Mental Illness Respite Care	4504103	AZ

General Provider Information

NPI Number	:	1235478892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISONA HEUSTED

Provider Business Mailing Address
First Line	:	3901 E EMILE ZOLA AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-6225
Country	:	US
Telephone Number	:	623-314-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 E EMILE ZOLA AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-6225
Country	:	US
Telephone Number	:	623-314-4500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	02/01/2013

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Directions to “ KRISONA HEUSTED ” Practice Location

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