Provider Demographics
NPI:1437682614
Name:PRESTIGE PSYCHIATRIC PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:PRESTIGE PSYCHIATRIC PROFESSIONALS, LLC
Other - Org Name:PRESTIGE PSYCHIATRIC PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:LARRALDE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:602-910-6519
Mailing Address - Street 1:3120 W CAREFREE HWY
Mailing Address - Street 2:STE 1-602
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3201
Mailing Address - Country:US
Mailing Address - Phone:602-910-6519
Mailing Address - Fax:602-910-6519
Practice Address - Street 1:8414 E SHEA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6665
Practice Address - Country:US
Practice Address - Phone:602-910-6519
Practice Address - Fax:602-910-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11647101YA0400X
AZLPC-11774101YP2500X
AZRN147893163WP0808X
AZAP5217363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty