Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | LAC-16025 | AZ |
NPI | 1003374349 |
---|---|
Provider Name | Carly Ann Welch |
First Address | Tempe, AZ 85282-5699 |
Second Address | Tempe, AZ 85282-2692 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2019 |
Last Update Date | 06/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
LAC-16025 | LICENSE (01) | AZ |