Provider Demographics
NPI:1326072372
Name:OSOLLO, REUBEN E (LCSW)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:E
Last Name:OSOLLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10613 N HAYDEN RD
Mailing Address - Street 2:STE J-100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5683
Mailing Address - Country:US
Mailing Address - Phone:480-206-8295
Mailing Address - Fax:480-951-4307
Practice Address - Street 1:10613 N HAYDEN RD
Practice Address - Street 2:STE J-100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5683
Practice Address - Country:US
Practice Address - Phone:480-206-8295
Practice Address - Fax:480-951-4307
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-28901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ73359Medicare ID - Type UnspecifiedSOCIAL WORKER