Provider Demographics
NPI:1841686078
Name:SPECTRUM VILLAGE, PLLC
Entity type:Organization
Organization Name:SPECTRUM VILLAGE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LICHTE-BRILL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:602-910-0526
Mailing Address - Street 1:4150 W PEORIA AVE
Mailing Address - Street 2:STE. 133
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3900
Mailing Address - Country:US
Mailing Address - Phone:602-910-0526
Mailing Address - Fax:602-346-0117
Practice Address - Street 1:4150 W PEORIA AVE
Practice Address - Street 2:STE. 133
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-3900
Practice Address - Country:US
Practice Address - Phone:602-910-0526
Practice Address - Fax:602-346-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ127103K00000X
AZ4484103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ462224OtherAHCCCS