MEDICARE: MULTISPORT PSYCHOLOGICAL CONSULTANTS, 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	103TC0700X	Clinical Psychologist	3865	AZ

General Provider Information

NPI Number	:	1689799959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULTISPORT PSYCHOLOGICAL CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	17235 N 75TH AVE
Second Line	:	SUITE E-170
City	:	GLENDALE
State	:	AZ
Zip	:	85308-0831
Country	:	US
Telephone Number	:	602-561-0920
Fax Number	:	623-486-1636

Provider Business Practice Location Address
First Line	:	17235 N 75TH AVE
Second Line	:	SUITE E-170
City	:	GLENDALE
State	:	AZ
Zip	:	85308-0831
Country	:	US
Telephone Number	:	602-561-0920
Fax Number	:	623-486-1636

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	IAN MARCUS STRICKLAND
Credential	:	PSY.D.
Telephone Number	:	602-561-0920

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/22/2020

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