Provider Demographics
NPI:1043930662
Name:ID SUBSTRATE, PLLC
Entity Type:Organization
Organization Name:ID SUBSTRATE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-561-7806
Mailing Address - Street 1:PO BOX 10044
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-0044
Mailing Address - Country:US
Mailing Address - Phone:602-405-4622
Mailing Address - Fax:602-264-8107
Practice Address - Street 1:4500 N 32ND ST STE 100A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3360
Practice Address - Country:US
Practice Address - Phone:602-200-8690
Practice Address - Fax:602-264-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty