Healthcare Provider Details

I. General information

NPI: 1609483825
Provider Name (Legal Business Name): WISEMIND SOBER LIVING AND TREATMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6234 W BEHREND DR APT 3105
GLENDALE AZ
85308-6919
US

IV. Provider business mailing address

5755 W IRMA LN
GLENDALE AZ
85308-9178
US

V. Phone/Fax

Practice location:
  • Phone: 480-665-5311
  • Fax:
Mailing address:
  • Phone: 563-265-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAMES DANIEL MCCREARY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 563-265-7211