Basic Information
| Provider Information | |||||||||
| NPI: | 1811360316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDEMPTION PSYCHIATRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 S VAL VISTA DR STE 137 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804718560 | ||||||||
| FaxNumber: | 8889798197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 S VAL VISTA DR STE 137 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804718560 | ||||||||
| FaxNumber: | 8889798197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4804718560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.