Provider Demographics
NPI:1265590418
Name:THIRAKUL, MARYANN BELTRAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:BELTRAN
Last Name:THIRAKUL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 S ALMA SCHOOL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3086
Mailing Address - Country:US
Mailing Address - Phone:480-344-7088
Mailing Address - Fax:480-744-2726
Practice Address - Street 1:2266 S. DOBSON RD.
Practice Address - Street 2:SUITE 200
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-775-5154
Practice Address - Fax:480-744-2726
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3783103TC1900X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140717Medicaid