Provider Demographics
NPI:1013561786
Name:VENTOLA, DAVID MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:VENTOLA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12008 N 22ND PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1008
Mailing Address - Country:US
Mailing Address - Phone:623-238-2844
Mailing Address - Fax:
Practice Address - Street 1:3450 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2331
Practice Address - Country:US
Practice Address - Phone:602-803-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical