Basic Information
| Provider Information | |||||||||
| NPI: | 1003854035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCWETHY | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3250 E 40TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853657748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283410335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3220 E 40TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853657748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283410335 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-11861 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 929101 | 01 | AZ | AHCCCS # | OTHER |