Basic Information
Provider Information | |||||||||
NPI: | 1396284816 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARR | ||||||||
FirstName: | HANNAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3620 N. 3RD STREET | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 85012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022307373 | ||||||||
FaxNumber: | 6024415836 | ||||||||
Practice Location | |||||||||
Address1: | 235 W WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | AVONDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853231848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022307373 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/16/2017 | ||||||||
LastUpdateDate: | 12/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 16514 | AZ | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | AZ |   | MEDICAID |