Provider Demographics
NPI:1902526247
Name:OBERMEYER, TODD VINCENT
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:VINCENT
Last Name:OBERMEYER
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 1:6013 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5932
Mailing Address - Country:US
Mailing Address - Phone:602-931-6337
Mailing Address - Fax:
Practice Address - Street 1:2111 E BASELINE RD STE C3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1521
Practice Address - Country:US
Practice Address - Phone:480-718-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-15615101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health