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NPI Code Detail

MEDICARE: SPECTRUM VILLAGE, PLLC

MEDICARE: SPECTRUM VILLAGE, PLLC
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
1103K00000XBehavior Analyst127AZ
2103TC0700XClinical Psychologist4484AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1462224OTHERAZAHCCCS

General Provider Information

NPI Number : 1841686078
Entity Type Code : Organization
Provider Name (Legal Business Name) : SPECTRUM VILLAGE, PLLC
Provider Business Mailing Address
First Line : 4150 W PEORIA AVE
Second Line : STE. 133
City : PHOENIX
State : AZ
Zip : 85029-3900
Country : US
Telephone Number : 602-910-0526
Fax Number : 602-346-0117
Provider Business Practice Location Address
First Line : 4150 W PEORIA AVE
Second Line : STE. 133
City : PHOENIX
State : AZ
Zip : 85029-3900
Country : US
Telephone Number : 602-910-0526
Fax Number : 602-346-0117
Authorized Official
Title or Position : CHIEF CLINICAL OFFICER
Name : DR. LORI KIM LICHTE-BRILL
Credential : PSY.D.
Telephone Number : 602-910-0526
Provider Enumeration Date : 04/14/2015
Last Update Date : 04/14/2015

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Directions to “SPECTRUM VILLAGE, PLLC ” Practice Location

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