MEDICARE: AMBER RICCI LAC

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	101YM0800X	Mental Health Counselor	LAC-16795	AZ

General Provider Information

NPI Number	:	1689184558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER RICCI LAC

Provider Business Mailing Address
First Line	:	3501 W MICHELLE DR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-2814
Country	:	US
Telephone Number	:	623-455-1102
Fax Number	:

Provider Business Practice Location Address
First Line	:	2939 W DURANGO ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-6357
Country	:	US
Telephone Number	:	602-876-4222
Fax Number	:

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

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	10/05/2017

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