Basic Information
| Provider Information | |||||||||
| NPI: | 1518363274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANDARIS | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E EARLL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025995404 | ||||||||
| FaxNumber: | 6025995704 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 E VALLEY AUTO DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026756185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2014 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | LPC-17000 | 01 | AZ | ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS | OTHER |