Provider Demographics
NPI:1588061634
Name:NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC
Entity type:Organization
Organization Name:NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:TOLLESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-821-5173
Mailing Address - Street 1:989 S MAIN ST
Mailing Address - Street 2:BOX 447
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4601
Mailing Address - Country:US
Mailing Address - Phone:928-821-3403
Mailing Address - Fax:928-282-1852
Practice Address - Street 1:2155 W SR 89A
Practice Address - Street 2:ST 105
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5468
Practice Address - Country:US
Practice Address - Phone:928-821-3403
Practice Address - Fax:928-282-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36928208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231772Medicaid
MT0000092216OtherBLUE CROSS BLUE SHIELD
MT000085117OtherMEDICARE ID
AZ36928OtherARIZONA MEDICAL BOARD
AZBT9527916OtherDEA
AZBT9527916OtherDEA