Provider Demographics
NPI:1114327921
Name:ELRAYAH, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:ELRAYAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1863
Mailing Address - Country:US
Mailing Address - Phone:602-243-7313
Mailing Address - Fax:
Practice Address - Street 1:2111 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1863
Practice Address - Country:US
Practice Address - Phone:602-243-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ603261103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities