Provider Demographics
NPI:1710043567
Name:REDD, MARILYN LAVETTE
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LAVETTE
Last Name:REDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:602-279-1431
Practice Address - Street 1:4449 N 12TH STREET
Practice Address - Street 2:SUITE A1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4596
Practice Address - Country:US
Practice Address - Phone:602-279-1427
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11743385HR2055X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child