Provider Demographics
NPI:1174102537
Name:PEARSON, CORDELL
Entity type:Individual
Prefix:
First Name:CORDELL
Middle Name:
Last Name:PEARSON
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 1:2574 W BENTRUP ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-1002
Mailing Address - Country:US
Mailing Address - Phone:480-256-9799
Mailing Address - Fax:
Practice Address - Street 1:10149 N 92ND ST STE 103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4557
Practice Address - Country:US
Practice Address - Phone:480-256-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC17606101YM0800X
AZLPC19817101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health