MEDICARE: DR. KALA ANNAMBHOTLA PH.D.

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	3452	AZ

General Provider Information

NPI Number	:	1790840510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KALA ANNAMBHOTLA PH.D.

Provider Business Mailing Address
First Line	:	3938 E GRANT RD # 212
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2559
Country	:	US
Telephone Number	:	520-334-5960
Fax Number	:	520-323-3739

Provider Business Practice Location Address
First Line	:	430 N TUCSON BLVD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-4745
Country	:	US
Telephone Number	:	520-325-4837
Fax Number	:	520-323-3739

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	07/15/2014

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