Provider Demographics
NPI:1114279114
Name:HAVATONE, ALFHONSO TRACEY (LCSW-11476)
Entity Type:Individual
Prefix:
First Name:ALFHONSO
Middle Name:TRACEY
Last Name:HAVATONE
Suffix:
Gender:M
Credentials:LCSW-11476
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11445 N 39TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3003
Mailing Address - Country:US
Mailing Address - Phone:602-434-5246
Mailing Address - Fax:
Practice Address - Street 1:10005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:480-362-5505
Practice Address - Fax:480-362-7586
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-11476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860143787OtherEMPLOYER