Provider Demographics
NPI:1023216645
Name:HUNT, CONNIE MARIE (PHD, DAC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:HUNT
Suffix:
Gender:F
Credentials:PHD, DAC
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:MARIE
Other - Last Name:COWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0001
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-263-1631
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1631
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1116103T00000X
4622103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273855Medicaid