Provider Demographics
NPI:1619030285
Name:SCHUTRUM, MARCI A (EDS)
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:A
Last Name:SCHUTRUM
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E HIDDENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-1924
Mailing Address - Country:US
Mailing Address - Phone:480-629-8934
Mailing Address - Fax:
Practice Address - Street 1:8700 S KYRENE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2108
Practice Address - Country:US
Practice Address - Phone:480-783-2985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3741764103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124346Medicaid