Provider Demographics
NPI:1952760894
Name:IWAI, CASEY (PSYD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:IWAI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 W ANSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-1764
Mailing Address - Country:US
Mailing Address - Phone:602-237-2157
Mailing Address - Fax:
Practice Address - Street 1:1705 E HANNA RD
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-9612
Practice Address - Country:US
Practice Address - Phone:602-882-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical