1164166377 NPI number — ELITE MENTAL HEALTH AND WELLNESS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164166377 NPI number — ELITE MENTAL HEALTH AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE MENTAL HEALTH AND WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164166377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6738 S TUCANA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85298-8784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-629-1828
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6738 S TUCANA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85298-8784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-629-1828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WAWERU
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
WAMUYU
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-629-1828

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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