Provider Demographics
NPI:1043493257
Name:FAILLA, LINDA LOUISE (MS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LOUISE
Last Name:FAILLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:LOUISE
Other - Last Name:MADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:4650 W SWEETWATER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1505
Mailing Address - Country:US
Mailing Address - Phone:602-347-2600
Mailing Address - Fax:602-347-2709
Practice Address - Street 1:4650 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1505
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:602-347-2709
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ583436Medicaid