Healthcare Provider Details

I. General information

NPI: 1427898675
Provider Name (Legal Business Name): PIVOT WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 05/27/2024
Certification Date: 05/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10654 N 60TH AVE APT 2019
GLENDALE AZ
85304-3784
US

IV. Provider business mailing address

10654 N 60TH AVE APT 2019
GLENDALE AZ
85304-3784
US

V. Phone/Fax

Practice location:
  • Phone: 404-680-6887
  • Fax:
Mailing address:
  • Phone: 404-680-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARITA EDWARDS
Title or Position: MANAGING MEMBER
Credential:
Phone: 404-680-6887