Provider Demographics
NPI:1881828259
Name:DENETSOSIE, VERDA (LISAC)
Entity type:Individual
Prefix:
First Name:VERDA
Middle Name:
Last Name:DENETSOSIE
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 N STEVES BLVD STE 11
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3959
Mailing Address - Country:US
Mailing Address - Phone:928-526-2968
Mailing Address - Fax:928-526-0708
Practice Address - Street 1:2717 N STEVES BLVD STE 11
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3959
Practice Address - Country:US
Practice Address - Phone:928-526-2968
Practice Address - Fax:928-526-0708
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10701101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)