Provider Demographics
NPI:1467481168
Name:ARIZONA-FAT, VIRGINIA (LISAC,CPS)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:
Last Name:ARIZONA-FAT
Suffix:
Gender:F
Credentials:LISAC,CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:KAIBETO
Mailing Address - State:AZ
Mailing Address - Zip Code:86053-2147
Mailing Address - Country:US
Mailing Address - Phone:928-673-3267
Mailing Address - Fax:928-673-3269
Practice Address - Street 1:337 N. NAVAJO DRIVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-6480
Practice Address - Fax:928-645-8158
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11471101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ972572Medicaid