MEDICARE: DR. CAROL ANN GEGENHEIMER PH.D., LISAC, LMFT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC-10198	AZ
2	106H00000X	Marriage & Family Therapist	LMFT-10101	AZ

General Provider Information

NPI Number	:	1437234325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL ANN GEGENHEIMER PH.D., LISAC, LMFT

Provider Business Mailing Address
First Line	:	17100 N 67TH AVENUE
Second Line	:	SUITE 400
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3698
Country	:	US
Telephone Number	:	602-938-3323
Fax Number	:	602-938-1626

Provider Business Practice Location Address
First Line	:	17100 N 67TH AVENUE
Second Line	:	SUITE 400
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3698
Country	:	US
Telephone Number	:	602-938-3323
Fax Number	:	602-938-1626

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/16/2013

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