Basic Information
Provider Information | |||||||||
NPI: | 1770168692 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INSIGHT PSYCHIATRY PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13855 E BEATTY RANCH RD | ||||||||
Address2: |   | ||||||||
City: | SONOITA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856376514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807981903 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25 EL CAMINO REAL STE 4 | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856352800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7206949908 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2021 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANCUSO | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: | DENISE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5202766326 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NP | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 361524 | 05 | AZ |   | MEDICAID |