Provider Demographics
NPI:1225106982
Name:CHAVEZ, THERESA
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7218 W RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-7626
Mailing Address - Country:US
Mailing Address - Phone:623-478-0572
Mailing Address - Fax:
Practice Address - Street 1:7218 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-7626
Practice Address - Country:US
Practice Address - Phone:623-478-0572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3971385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ992778OtherAHCCCS ID NUMBER