Provider Demographics
NPI:1063551166
Name:BRAZZEL, KRISTINE (PSYD, LPC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BRAZZEL
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:SHARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13051
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85216-3051
Mailing Address - Country:US
Mailing Address - Phone:480-228-2367
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE
Practice Address - Street 2:1008
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2569
Practice Address - Country:US
Practice Address - Phone:480-228-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2390101YP2500X
AZ3823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120246Medicare PIN