Basic Information
Provider Information | |||||||||
NPI: | 1801097167 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RATHBUN | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | KENT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20402 N 15TH AVE | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850273636 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6234454952 | ||||||||
FaxNumber: | 6234455086 | ||||||||
Practice Location | |||||||||
Address1: | 6150 W GREENBRIAR DR | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853083724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024675500 | ||||||||
FaxNumber: | 6024675580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 103TS0200X | 3804461 | AZ | Y |   | Behavioral Health & Social Service Providers | Psychologist | School | 103TS0200X |   | CA | N |   | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.