Provider Demographics
NPI:1770347957
Name:HADDAD, VINCENT J
Entity type:Individual
Prefix:PROF
First Name:VINCENT
Middle Name:J
Last Name:HADDAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:PINE
Mailing Address - State:AZ
Mailing Address - Zip Code:85544-0695
Mailing Address - Country:US
Mailing Address - Phone:602-980-2036
Mailing Address - Fax:
Practice Address - Street 1:6765 W BRADSHAW DR # 695
Practice Address - Street 2:
Practice Address - City:PINE
Practice Address - State:AZ
Practice Address - Zip Code:85544-5089
Practice Address - Country:US
Practice Address - Phone:602-980-2036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC0-702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional