Provider Demographics
NPI:1619658838
Name:BIRDSALL, MARIA J (MS, LAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:J
Last Name:BIRDSALL
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:884 S ADAM WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1486
Mailing Address - Country:US
Mailing Address - Phone:956-223-0726
Mailing Address - Fax:
Practice Address - Street 1:4864 E BASELINE RD STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4629
Practice Address - Country:US
Practice Address - Phone:480-999-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20630101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor