Provider Demographics
NPI:1255636767
Name:ARIZONA IN LOVE PLLC
Entity type:Organization
Organization Name:ARIZONA IN LOVE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEPACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-371-4773
Mailing Address - Street 1:21150 N TATUM BLVD
Mailing Address - Street 2:#4012
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4292
Mailing Address - Country:US
Mailing Address - Phone:480-371-4773
Mailing Address - Fax:
Practice Address - Street 1:11000 N SCOTTSDALE RD
Practice Address - Street 2:STE. 163
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6130
Practice Address - Country:US
Practice Address - Phone:480-922-5440
Practice Address - Fax:480-922-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4061103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912924853OtherINDIVIDUAL NPI
=========OtherEIN