MEDICARE: AHWATUKEE PSYCHOLOGY LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1326608290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AHWATUKEE PSYCHOLOGY LLC

Provider Business Mailing Address
First Line	:	11011 S 48TH ST STE 106
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-1787
Country	:	US
Telephone Number	:	480-223-8263
Fax Number	:

Provider Business Practice Location Address
First Line	:	11011 S 48TH ST STE 106
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-1787
Country	:	US
Telephone Number	:	480-223-8263
Fax Number	:	480-247-5705

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MYSTI RAINWATER
Credential	:	LPC
Telephone Number	:	480-223-8263

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	01/21/2025

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