Healthcare Provider Details

I. General information

NPI: 1053294017
Provider Name (Legal Business Name): LUMINA MIND AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14441 W MCDOWELL RD STE B102
GOODYEAR AZ
85395-2519
US

IV. Provider business mailing address

20044 N 68TH DR
GLENDALE AZ
85308-5594
US

V. Phone/Fax

Practice location:
  • Phone: 602-763-8652
  • Fax:
Mailing address:
  • Phone: 602-763-8652
  • 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 Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA M ROSS
Title or Position: CEO
Credential: PMHNP-BC
Phone: 602-763-8652