MEDICARE: DR. LISA ELDER OUTHIER PSY.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	103TC2200X	Clinical Child & Adolescent Psychologist	3909	AZ

General Provider Information

NPI Number	:	1811257264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA ELDER OUTHIER PSY.D.

Provider Business Mailing Address
First Line	:	7330 N 16TH ST
Second Line	:	C-200
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5237
Country	:	US
Telephone Number	:	602-795-1670
Fax Number	:	602-795-1699

Provider Business Practice Location Address
First Line	:	7330 N 16TH ST
Second Line	:	C-200
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5237
Country	:	US
Telephone Number	:	602-795-1670
Fax Number	:	602-795-1699

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

Provider Enumeration Date	:	05/19/2012
Last Update Date	:	05/28/2012

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