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NPI Code Detail

MEDICARE: RANDI JANELLE GENNARO MSC, LAC

MEDICARE: RANDI JANELLE GENNARO MSC, LAC
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
1101Y00000XCounselorLAC- 13883AZ

General Provider Information

NPI Number : 1265861959
Entity Type Code : Individual
Provider Name (Legal Business Name) : RANDI JANELLE GENNARO MSC, LAC
Provider Business Mailing Address
First Line : 4414 N 19TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-4114
Country : US
Telephone Number : 602-285-5550
Fax Number :
Provider Business Practice Location Address
First Line : 4414 N 19TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-4114
Country : US
Telephone Number : 602-285-5550
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/04/2013
Last Update Date : 11/04/2013

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