Provider Demographics
NPI:1538856695
Name:JOHN, AMALA (LCSW)
Entity type:Individual
Prefix:
First Name:AMALA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 S VAL VISTA DR STE A3-659
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1374
Mailing Address - Country:US
Mailing Address - Phone:480-269-2971
Mailing Address - Fax:480-452-0691
Practice Address - Street 1:4001 E BASELINE RD STE 204
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2743
Practice Address - Country:US
Practice Address - Phone:480-269-2971
Practice Address - Fax:480-452-0691
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ213111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical