Basic Information
| Provider Information | |||||||||
| NPI: | 1013311356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOSE | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E. EARLL DR. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6025995711 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 W. SOUTHERN AVE. | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6025995711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2014 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-10407 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.