Basic Information
| Provider Information | |||||||||
| NPI: | 1154499853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOCA | ||||||||
| FirstName: | PEDRO | ||||||||
| MiddleName: | RAMON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234346200 | ||||||||
| FaxNumber: | 6237803752 | ||||||||
| Practice Location | |||||||||
| Address1: | 4131 N 24TH ST | ||||||||
| Address2: | STE. B102 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029556632 | ||||||||
| FaxNumber: | 6023811341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-0638 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | 847 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 763290 | 01 | AETNA BEHAVIORAL HEALTH | OTHER | AZ0616080 | 01 | AZ | BLUE CROSS BLUE SHIELD AZ | OTHER | 068297000 | 01 | MAGELLAN BEHAVIORAL HEALT | OTHER |