SPECTRUM VILLAGE, PLLC , NPI 1841686078 — PHOENIX (AZ)

NPI 1841686078

4+ Years Experience Organization

SPECTRUM VILLAGE, PLLC

04/14/2015
PROVIDER ENUMERATION DATE
04/14/2015
LAST UPDATE DATE
1841686078
NPI NUMBER

About SPECTRUM VILLAGE, PLLC

SPECTRUM VILLAGE, PLLC is a provider established in PHOENIX, AZ. The NPI number of SPECTRUM VILLAGE, PLLC is 1841686078 and was assigned on 04/14/2015. The practitioners primary taxonomy code is: 103K00000X with license number: 127 AZ .

Mailing address

  • City: PHOENIX
  • State: AZ
  • Postal code: 850293900
  • Phone: 6029100526
  • Fax: 6023460117
  • Address: 4150 W PEORIA AVE
  • Address 2: STE. 133

Primary Practice Address

  • Region : PHOENIX, AZ
  • NPI : 1841686078
  • Phone : 6029100526
  • Fax : 6023460117
  • Postalcode : 850293900
  • Address : 4150 W PEORIA AVE STE. 133

Additional identifiers

  • Identifier: 462224
  • Code / Type : 1 - other
  • Identifier state : AZ
  • Identifier issuer: AHCCCS

Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Provider taxonomy - Behavior Analyst

  • Taxonomy code: 103K00000X
  • License number: 127
  • License state: AZ

The taxonomy is not the primary taxonomy.

Taxonomy group: 193200000X MULTI-SPECIALTY GROUP.

Taxonomy description: A behavior analyst is qualified by at least a master"s degree and Behavior Analyst Certification Board certification and/or a state-issued credential (such as a license) to practice behavior analysis independently. Behavior analysts provide the required supervision to assistant behavior analysts and behavior technicians. A behavior analyst delivers services consistent with the dimensions of applied behavior analysis. Common services may include, but are not limited to, conducting behavioral assessments, analyzing data, writing and revising behavior-analytic treatment plans, training others to implement components of treatment plans, and overseeing implementation of treatment plans.

Healthcare provider taxonomy #2 - Psychologist

  • Taxonomy code: 103TC0700X
  • License number: 4484
  • License state: AZ

The taxonomy is the primary taxonomy (there can be only one per NPI record).

Taxonomy description: A psychologist who provides continuing and comprehensive mental and behavioral health care for individuals and families; consultation to agencies and communities; training, education and supervision; and research-based practice. It is a specialty in breadth -- one that is broadly inclusive of severe psychopathology -- and marked by comprehensiveness and integration of knowledge and skill from a broad array of disciplines within and outside of psychology proper. The scope of clinical psychology encompasses all ages, multiple diversities and varied systems.

Contacts:

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  • SPECTRUM VILLAGE, PLLC
  • Address : 4150 W PEORIA AVE STE. 133
  • Region : PHOENIX, AZ
  • NPI : 1841686078
  • Phone : 6029100526
  • Fax : 6023460117
  • Postalcode : 850293900

Authorized official :

{:AUTHORIZED_OFFICIAL_FIRST_NAME:} {:AUTHORIZED_OFFICIAL_MIDDLE_NAME:} {:AUTHORIZED_OFFICIAL_LAST_NAME:}
  • Phone : 6029100526
  • Title or position : CHIEF CLINICAL OFFICER
  • Credentials : PSY.D.

Reference NPI Information. Full replica of the CMS (NPPES) NPI record

Field Name Value
Provider First Line Business Practice Location Address4150 W PEORIA AVE
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location AddressSTE. 133
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City NamePHOENIX
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State NameAZ
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code850293900
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Telephone Number6029100526
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number6023460117
The fax number associated with the location address of the provider being identified.
NPI1841686078
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Healthcare Provider Taxonomy 1103K00000X
A behavior analyst is qualified by at least a master"s degree and Behavior Analyst Certification Board certification and/or a state-issued credential (such as a license) to practice behavior analysis independently. Behavior analysts provide the required supervision to assistant behavior analysts and behavior technicians. A behavior analyst delivers services consistent with the dimensions of applied behavior analysis. Common services may include, but are not limited to, conducting behavioral assessments, analyzing data, writing and revising behavior-analytic treatment plans, training others to implement components of treatment plans, and overseeing implementation of treatment plans.
Provider Enumeration Date04/14/2015
The date the provider was assigned a unique identifier (assigned an NPI).
Last Updated04/14/2015
The date that a record was last updated or changed.
Entity TypeOrganization
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Is Organization SubpartN
The "Is the organization a subpart?" question must be answered. If the organization is a subpart, the Parent Organization Legal Business Name (LBN) and Parent Organization Taxpayer Identification Number (TIN) fields must be completed. The Parent Organization LBN and TIN fields can only be completed if the answer to the subpart question is Yes. Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents"). Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents": (1) The psychiatric unit in a hospital is not a legal entity but is part of the hospital (the "parent"), which is a legal entity. The legal entity must obtain an NPI. The psychiatric unit is an example of a subpart that could have its own NPI if the hospital determines that it should. (2) A group practice that is not a sole proprietorship has a main location and could have other offices in different locations, but each office is not a separate legal entity; instead, each office is part of the corporation (the "parent") which is a legal entity. The offices are examples of subparts that could have their own NPIs if the main location determines that they should. (3) A pharmacy fills prescriptions for patients whose physicians have prescribed medications for them and may also rent or sell durable medical equipment to patients whose physicians have ordered such equipment for them. Neither the pharmacy line of business nor the DME line of business represent legal entities; instead, both lines of business are part of an organization (the "parent") that is a legal entity. Each line of business represents a different Healthcare Provider Taxonomy or area of specialization that often submits its own electronic claims to health plans. The "parent"-we don"t know who the parent is in this example-must ensure that each subpart that submits its own claims to health plans has its own NPI.
Provider Organization Name (Legal Business Name)SPECTRUM VILLAGE, PLLC
Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Line Business Mailing Address4150 W PEORIA AVE
The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Second Line Business Mailing AddressSTE. 133
The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
Provider Business Mailing Address City NamePHOENIX
The City name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address City name".
Provider Business Mailing Address State NameAZ
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code850293900
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Telephone Number6029100526
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider Business Mailing Address Fax Number6023460117
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Authorized Official Last NameLICHTE-BRILL
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First NameLORI
The first name of the authorized official
Authorized Official Middle NameKIM
The middle name of the authorized official
Authorized Official Title or PositionCHIEF CLINICAL OFFICER
The title or position of the authorized official
Authorized Official Name Prefix TextDR.
Authorized Official Name Prefix Text
Authorized Official Credential TextPSY.D.
Authorized Official Credential Text
Authorized Official Telephone Number6029100526
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code #1103K00000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1Behavior Analyst
A behavior analyst is qualified by at least a master"s degree and Behavior Analyst Certification Board certification and/or a state-issued credential (such as a license) to practice behavior analysis independently. Behavior analysts provide the required supervision to assistant behavior analysts and behavior technicians. A behavior analyst delivers services consistent with the dimensions of applied behavior analysis. Common services may include, but are not limited to, conducting behavioral assessments, analyzing data, writing and revising behavior-analytic treatment plans, training others to implement components of treatment plans, and overseeing implementation of treatment plans.
Provider License Number 1127
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 1AZ
Healthcare Provider Primary Taxonomy Switch 1N
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Healthcare Provider Taxonomy Code 2103TC0700X
Healthcare Provider Taxonomy 2Psychologist
A psychologist who provides continuing and comprehensive mental and behavioral health care for individuals and families; consultation to agencies and communities; training, education and supervision; and research-based practice. It is a specialty in breadth -- one that is broadly inclusive of severe psychopathology -- and marked by comprehensiveness and integration of knowledge and skill from a broad array of disciplines within and outside of psychology proper. The scope of clinical psychology encompasses all ages, multiple diversities and varied systems.
Provider License Number 24484
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 2AZ
Healthcare Provider Primary Taxonomy Switch 2Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Other Provider Identifier 1462224
Other Provider Identifier #1
Other Provider Identifier Type 11
  • 1 - Other
  • 5 - MEDICAID
Other Provider Identifier State 1AZ
Other Provider Identifier State #1
Other Provider Identifier Issuer 1AHCCCS
Other Provider Identifier Issuer #1
X

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