Basic Information
| Provider Information | |||||||||
| NPI: | 1114371325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURFEY | ||||||||
| FirstName: | MIKAELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2850 NORTH COUNTRY CLUB ROAD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857161910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203226274 | ||||||||
| FaxNumber: | 5205094496 | ||||||||
| Practice Location | |||||||||
| Address1: | 5240 EAST KNIGHT DRIVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202091919 | ||||||||
| FaxNumber: | 5202076200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-16957 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 330955 | 05 | AZ | MEDICAID |