Provider Demographics
NPI:1013311356
Name:CLOSE, CHAD H (LISAC)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:H
Last Name:CLOSE
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E. EARLL DR.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:602-599-5711
Practice Address - Street 1:650 W. SOUTHERN AVE.
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210
Practice Address - Country:US
Practice Address - Phone:602-808-2800
Practice Address - Fax:602-599-5711
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)