MEDICARE: MRS. MARY KEADY MAUDSLEY MA LPC

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	103T00000X	Psychologist	LPC1262	AZ
2	106H00000X	Marriage & Family Therapist	MP19615	CA

General Provider Information

NPI Number	:	1619071909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY KEADY MAUDSLEY MA LPC

Provider Business Mailing Address
First Line	:	10000 N 31ST AVE
Second Line	:	A-105
City	:	PHOENIX
State	:	AZ
Zip	:	85051-9582
Country	:	US
Telephone Number	:	602-843-0000
Fax Number	:	602-843-0000

Provider Business Practice Location Address
First Line	:	10000 N 31ST AVE
Second Line	:	A-105
City	:	PHOENIX
State	:	AZ
Zip	:	85051-9582
Country	:	US
Telephone Number	:	602-843-0000
Fax Number	:	602-843-0000

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

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	05/05/2009

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