Provider Demographics
NPI:1417301086
Name:PROCH, KRISTI (LAC)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:PROCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E TONOPAH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-9108
Mailing Address - Country:US
Mailing Address - Phone:602-738-8300
Mailing Address - Fax:623-581-9319
Practice Address - Street 1:21448 N 75TH AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5978
Practice Address - Country:US
Practice Address - Phone:623-572-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC13937101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor