Provider Demographics
NPI:1730115890
Name:KIRKLEY, TRUDY S (LCSW)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:S
Last Name:KIRKLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MOONLIGHT CIR
Mailing Address - Street 2:#260
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-9775
Mailing Address - Country:US
Mailing Address - Phone:928-634-2236
Mailing Address - Fax:928-634-8960
Practice Address - Street 1:8 E COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4382
Practice Address - Country:US
Practice Address - Phone:928-634-2236
Practice Address - Fax:928-634-8960
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-114891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ871667Medicaid
AZ108070Medicare ID - Type Unspecified