Provider Demographics
NPI:1912372822
Name:SELF
Entity Type:Organization
Organization Name:SELF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAIMONDI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC 14499/LISAC 1158
Authorized Official - Phone:602-569-4328
Mailing Address - Street 1:5010 E SHEA BLVD STE D202
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4570
Mailing Address - Country:US
Mailing Address - Phone:602-569-4328
Mailing Address - Fax:602-569-4378
Practice Address - Street 1:5010 E SHEA BLVD STE D202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4570
Practice Address - Country:US
Practice Address - Phone:602-569-4328
Practice Address - Fax:602-569-4378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 14499251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health