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NPI Code Detail

MEDICARE: MS. SHIRLEY VIVES LAC

MEDICARE: MS. SHIRLEY VIVES 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
1101YM0800XMental Health CounselorLAC12380AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1LAC12380OTHERAZLICENSE

General Provider Information

NPI Number : 1730385808
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. SHIRLEY VIVES LAC
Provider Business Mailing Address
First Line : 4220 N 20TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-5101
Country : US
Telephone Number : 602-279-7655
Fax Number : 602-241-5756
Provider Business Practice Location Address
First Line : 3306 W CATALINA DR
Second Line :
City : PHOENIX
State : AZ
Zip : 85017-5291
Country : US
Telephone Number : 602-353-0703
Fax Number : 602-353-0715
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/25/2007
Last Update Date : 07/08/2007

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Directions to “ MS. SHIRLEY VIVES LAC” Practice Location

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