Provider Demographics
NPI:1467268607
Name:RATHBURN, ERIC DANIEL
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DANIEL
Last Name:RATHBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N 99TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5327
Mailing Address - Country:US
Mailing Address - Phone:602-540-1271
Mailing Address - Fax:
Practice Address - Street 1:824 N 99TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5327
Practice Address - Country:US
Practice Address - Phone:602-540-1271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist