Provider Demographics
NPI:1346349149
Name:SURETTE, IRIS H (PHD)
Entity Type:Individual
Prefix:DR
First Name:IRIS
Middle Name:H
Last Name:SURETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 655
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:AZ
Mailing Address - Zip Code:85611
Mailing Address - Country:US
Mailing Address - Phone:520-456-9799
Mailing Address - Fax:520-456-1703
Practice Address - Street 1:805 E FREMONT
Practice Address - Street 2:TOMBSTONE UNIFIED SCHOOL DIST
Practice Address - City:TOMBSTONE
Practice Address - State:AZ
Practice Address - Zip Code:85638
Practice Address - Country:US
Practice Address - Phone:520-456-9842
Practice Address - Fax:520-457-3720
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ620220Medicaid