MEDICARE: EAST VALLEY TRAUMA COUNSELING LLC

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	1041C0700X	Clinical Social Worker	16034	AZ

General Provider Information

NPI Number	:	1992227235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY TRAUMA COUNSELING LLC

Provider Business Mailing Address
First Line	:	3641 W LAREDO ST
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85226-2233
Country	:	US
Telephone Number	:	480-776-4155
Fax Number	:

Provider Business Practice Location Address
First Line	:	1166 E WARNER RD STE 206
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-3066
Country	:	US
Telephone Number	:	480-462-7728
Fax Number	:	480-452-1530

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	STACY DELUCA
Credential	:
Telephone Number	:	602-741-3077

Provider Enumeration Date	:	07/07/2017
Last Update Date	:	10/29/2019

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