Healthcare Provider Details

I. General information

NPI: 1174292221
Provider Name (Legal Business Name): PHOENIX HOLISTIC PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2021
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S HIGLEY RD STE 104
GILBERT AZ
85296-4798
US

IV. Provider business mailing address

929 N VAL VISTA DR STE 109-130
GILBERT AZ
85234-3706
US

V. Phone/Fax

Practice location:
  • Phone: 480-470-0069
  • Fax:
Mailing address:
  • Phone: 480-470-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PANCHAJANYA PAUL
Title or Position: OWNER
Credential: MD
Phone: 678-250-8883