1891043311 NPI number — EAST VALLEY MENTAL WELLNESS PLLC

Table of content: (NPI 1891043311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891043311 NPI number — EAST VALLEY MENTAL WELLNESS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VALLEY MENTAL WELLNESS PLLC
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:
1891043311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1166 E WARNER RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-3064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-570-0497
Provider Business Mailing Address Fax Number:
480-452-0145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1166 E WARNER RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296-3064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-570-0497
Provider Business Practice Location Address Fax Number:
480-452-0145
Provider Enumeration Date:
08/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CASEY
Authorized Official First Name:
ANN MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
480-570-0497

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  AP4476 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 726497 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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