MEDICARE: ELIJAH GARCIA

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	101YP2500X	Professional Counselor	LPC-21790	AZ

General Provider Information

NPI Number	:	1558055830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH GARCIA

Provider Business Mailing Address
First Line	:	PO BOX 748465
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8465
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:	617-807-0958

Provider Business Practice Location Address
First Line	:	1110 E MISSOURI AVE STE 340
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2753
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:	617-807-0958

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

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	06/08/2023

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