Provider Demographics
NPI:1518141985
Name:ANXIETY DISORDERS AND MEDICAL PSYCHOLOGY TREATMENT CENTER, P.C.
Entity Type:Organization
Organization Name:ANXIETY DISORDERS AND MEDICAL PSYCHOLOGY TREATMENT CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AZ LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMNER
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:SYDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-779-3783
Mailing Address - Street 1:617 N HUMPHREYS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3063
Mailing Address - Country:US
Mailing Address - Phone:928-779-3783
Mailing Address - Fax:928-773-1150
Practice Address - Street 1:617 N HUMPHREYS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3063
Practice Address - Country:US
Practice Address - Phone:928-779-3783
Practice Address - Fax:928-773-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120604Medicare PIN