Provider Demographics
NPI:1619609203
Name:STICH, MARY ANNE (LISAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNE
Last Name:STICH
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 E INDIAN SCHOOL RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0703
Mailing Address - Country:US
Mailing Address - Phone:602-492-1010
Mailing Address - Fax:888-434-5444
Practice Address - Street 1:2633 E INDIAN SCHOOL RD STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-0703
Practice Address - Country:US
Practice Address - Phone:602-492-1010
Practice Address - Fax:888-434-5444
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-155249101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)