Healthcare Provider Details

I. General information

NPI: 1093167108
Provider Name (Legal Business Name): TBM MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17431 N 71ST DR SUITE 104
GLENDALE AZ
85308-8598
US

IV. Provider business mailing address

17431 N 71ST DR SUITE 104
GLENDALE AZ
85308-8598
US

V. Phone/Fax

Practice location:
  • Phone: 480-521-6586
  • Fax:
Mailing address:
  • Phone: 480-521-6586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRN1348
License Number StateAZ

VIII. Authorized Official

Name: TIMOTHY MILLER
Title or Position: MBR
Credential:
Phone: 480-521-6586