Provider Demographics
NPI: | 1639931702 |
---|---|
Name: | STITH, BRANDY (MA) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRANDY |
Middle Name: | |
Last Name: | STITH |
Suffix: | |
Gender: | F |
Credentials: | MA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 17505 N 79TH AVE STE 105 |
Mailing Address - Street 2: | |
Mailing Address - City: | GLENDALE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85308-8724 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-989-8899 |
Mailing Address - Fax: | 602-900-0969 |
Practice Address - Street 1: | 17505 N 79TH AVE STE 105 |
Practice Address - Street 2: | |
Practice Address - City: | GLENDALE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85308-8724 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-989-8899 |
Practice Address - Fax: | 602-900-0969 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2024-01-25 |
Last Update Date: | 2024-03-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | MA | 101Y00000X, 101Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101Y00000X | Behavioral Health & Social Service Providers | Counselor |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 1043982747 | Other | HEALING HARTZE TYPE 2 ORGANIZATIONAL NPI |
AZ | 1740851542 | Other | JANUARY HARTZE OF HEALING HARTZE INDIVIDUAL NPI |
AZ | CSLG13230 | Other | ARIZONA DHS |
AZ | 125011 | Medicaid |