MEDICARE: ARIZONA WELLCARE 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	103TB0200X	Cognitive & Behavioral Psychologist

General Provider Information

NPI Number	:	1366088585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA WELLCARE LLC

Provider Business Mailing Address
First Line	:	2515 E THOMAS RD STE 16
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7946
Country	:	US
Telephone Number	:	866-661-3816
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 E THOMAS RD STE 16
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7946
Country	:	US
Telephone Number	:	866-661-3816
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RHONDA RUSSELL
Credential	:
Telephone Number	:	866-661-3816

Provider Enumeration Date	:	11/22/2019
Last Update Date	:	11/22/2019

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Directions to “ARIZONA WELLCARE LLC ” Practice Location

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