Provider Demographics
NPI:1396410650
Name:ST. CATHERINE, CLARE DAHLIA
Entity type:Individual
Prefix:
First Name:CLARE
Middle Name:DAHLIA
Last Name:ST. CATHERINE
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 1:6605 N 19TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1628
Mailing Address - Country:US
Mailing Address - Phone:917-755-0025
Mailing Address - Fax:
Practice Address - Street 1:6605 N 19TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1628
Practice Address - Country:US
Practice Address - Phone:917-755-0025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4140670103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool