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NPI Code Detail

MEDICARE: WENDY RAE DWAN

MEDICARE: WENDY RAE DWAN
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 CounselorLAC-19109AZ

General Provider Information

NPI Number : 1790486900
Entity Type Code : Individual
Provider Name (Legal Business Name) : WENDY RAE DWAN
Provider Business Mailing Address
First Line : 1580 N KOLB RD STE 100
Second Line :
City : TUCSON
State : AZ
Zip : 85715-4932
Country : US
Telephone Number : 520-214-8650
Fax Number :
Provider Business Practice Location Address
First Line : 1580 N KOLB RD STE 100
Second Line :
City : TUCSON
State : AZ
Zip : 85715-4932
Country : US
Telephone Number : 520-214-8650
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/14/2023
Last Update Date : 03/14/2023

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