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Addiction (Substance Use Disorder) >> Counselor >> Behavioral Health & Social Service Providers

Registrant NPI Number: 1053970830

Individual Registrant:
Gender: M
Not Sole Proprietor

Location and contact information for practice:
13110 E PONCE ST  DEWEY, AZ 86327-7161 US
Tel: 928-830-1401  Fax: --

Contact information for business:
13110 E PONCE ST  DEWEY, AZ 86327-7161 US
Tel: 928-830-1401  Fax: --

Registration Information:
NPI: 1053970830
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y101YA0400XBehavioral Health & Social Service Providers
Addiction (Substance Use Disorder)

Legacy codes, insurance codes and state license numbers:



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