Provider Demographics
NPI:1790445328
Name:BACH, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:BACH
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 1:191 W DEUCE OF CLUBS UNIT 2815
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-4490
Mailing Address - Country:US
Mailing Address - Phone:808-772-9509
Mailing Address - Fax:
Practice Address - Street 1:2500 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7994
Practice Address - Country:US
Practice Address - Phone:928-537-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19870101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor