Provider Demographics
NPI:1902264773
Name:DUDLESTON BRACAMONTE, DARCY (LISAC)
Entity Type:Individual
Prefix:MRS
First Name:DARCY
Middle Name:
Last Name:DUDLESTON BRACAMONTE
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:MRS
Other - First Name:DARCY
Other - Middle Name:
Other - Last Name:BRACAMONTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISAC
Mailing Address - Street 1:17505 N 79TH AVE
Mailing Address - Street 2:302A
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8725
Mailing Address - Country:US
Mailing Address - Phone:623-850-5404
Mailing Address - Fax:
Practice Address - Street 1:17505 N. 79TH AVE
Practice Address - Street 2:302A
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-850-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11520101YA0400X
AZLAC-11168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health