Healthcare Provider Details

I. General information

NPI: 1134817265
Provider Name (Legal Business Name): LAVENDER FOUNDATION OF LOVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9820 N 49TH AVE
GLENDALE AZ
85302-2411
US

IV. Provider business mailing address

9820 N 49TH AVE
GLENDALE AZ
85302-2411
US

V. Phone/Fax

Practice location:
  • Phone: 602-581-1588
  • Fax:
Mailing address:
  • Phone: 602-581-1588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: ZUHAL FADL
Title or Position: CEO
Credential:
Phone: 602-581-1588